Provider Demographics
NPI:1285779447
Name:GUGISBERG, ELLEN (MED)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:GUGISBERG
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 SUNGATE DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2311
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:701-451-5057
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND58103-A004OtherTRIWEST
NDHP70690OtherHEALTH PARTNERS
ND2040318OtherCIGNA
ND9397797OtherPHCS
MN309S8GUOtherBCBSMN
MN17979OtherBCBSND
MN2352431OtherAMERICA'S PPO
ND62-87355OtherMEDICA UBH