MEDICARE: DR. JOHNA C HARTNELL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1129	NM
2	103T00000X	Psychologist	1116-57	WI
3	103T00000X	Psychologist	0035	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	000684106	OTHER	WI	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	HSZI31ZJSB	OTHER	ND	INDIAN HEALTH SERVICE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558377796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHNA C HARTNELL PH.D.

Provider Business Mailing Address
First Line	:	PO BOX J
Second Line	:	PHS INDIAN HEALTH SERVICE, DIR. BEHAVIORAL HEALTH
City	:	FORT YATES
State	:	ND
Zip	:	58538-0527
Country	:	US
Telephone Number	:	701-854-8276
Fax Number	:	701-854-3844

Provider Business Practice Location Address
First Line	:	10 NORTH RIVER ROAD
Second Line	:	PHS INDIAN HEALTH SERVICE
City	:	FORT YATES
State	:	ND
Zip	:	58538-0797
Country	:	US
Telephone Number	:	701-854-3831
Fax Number	:	701-854-3844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/29/2015

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Directions to “ DR. JOHNA C HARTNELL PH.D.” Practice Location

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