Provider Demographics
NPI:1366117715
Name:VON WAHLDE, SHELBY K (MOTR/L)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:K
Last Name:VON WAHLDE
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:WITTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:2625 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0574
Mailing Address - Country:US
Mailing Address - Phone:701-222-3175
Mailing Address - Fax:701-222-3186
Practice Address - Street 1:2625 N 19TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0574
Practice Address - Country:US
Practice Address - Phone:701-222-3175
Practice Address - Fax:701-222-3186
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1870225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1483143Medicaid