Healthcare Provider Details

I. General information

NPI: 1225583636
Provider Name (Legal Business Name): RAY TALLEY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 S 12TH ST
BISMARCK ND
58504-5977
US

IV. Provider business mailing address

128 SOO LINE DR
BISMARCK ND
58501-3339
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-4000
  • Fax:
Mailing address:
  • Phone: 701-323-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6952
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: