Healthcare Provider Details

I. General information

NPI: 1881526556
Provider Name (Legal Business Name): GRAND MESA THERAPY WASHINGTON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S 12TH ST
BISMARCK ND
58504-5910
US

IV. Provider business mailing address

610 S 12TH ST
BISMARCK ND
58504-5910
US

V. Phone/Fax

Practice location:
  • Phone: 970-787-5100
  • Fax: 970-787-5100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: HOLLY SHOCKLEY
Title or Position: OWNER
Credential:
Phone: 970-787-5100