Provider Demographics
NPI:1699081539
Name:ELLENSON, NATHAN JOHN (LPC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOHN
Last Name:ELLENSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S 4TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4715
Mailing Address - Country:US
Mailing Address - Phone:701-795-3000
Mailing Address - Fax:701-795-3050
Practice Address - Street 1:151 S 4TH ST STE 401
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-795-3000
Practice Address - Fax:701-795-3050
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251B00000X
ND1001-4-15-19101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management