Healthcare Provider Details

I. General information

NPI: 1528808573
Provider Name (Legal Business Name): PSYCH 180 PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 7TH ST W
DICKINSON ND
58601-4335
US

IV. Provider business mailing address

30 7TH ST W
DICKINSON ND
58601-4335
US

V. Phone/Fax

Practice location:
  • Phone: 701-690-2360
  • Fax: 701-291-4747
Mailing address:
  • Phone: 208-794-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLY M CHEVALIER
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 701-690-2360