Provider Demographics
NPI:1407344286
Name:HYSTAD-MOE, CHARLIE RAY (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:RAY
Last Name:HYSTAD-MOE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 1ST AVE W STE 4
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6286
Mailing Address - Country:US
Mailing Address - Phone:701-572-3335
Mailing Address - Fax:701-572-3337
Practice Address - Street 1:2224 1ST AVE W STE 4
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6286
Practice Address - Country:US
Practice Address - Phone:701-572-3335
Practice Address - Fax:701-572-3337
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
ND53341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker