Provider Demographics
NPI:1528808573
Name:PSYCH 180 PLLC
Entity type:Organization
Organization Name:PSYCH 180 PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHEVALIER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:701-690-2360
Mailing Address - Street 1:1665 PRAIRIE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2997
Mailing Address - Country:US
Mailing Address - Phone:208-794-5314
Mailing Address - Fax:
Practice Address - Street 1:30 7TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-690-2360
Practice Address - Fax:701-291-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-28
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)