Healthcare Provider Details

I. General information

NPI: 1447748918
Provider Name (Legal Business Name): CHRYSALIS BEHAVIORAL HEALTH SERVICES AND TRAINING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 16TH AVE S
FARGO ND
58103-4055
US

IV. Provider business mailing address

102 W BEATON DR STE 103
WEST FARGO ND
58078-2653
US

V. Phone/Fax

Practice location:
  • Phone: 701-260-0713
  • Fax:
Mailing address:
  • Phone: 701-260-0713
  • Fax: 701-356-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA MARIE CAVETT
Title or Position: CLINICAL DIRECTOR, PSYCHOLOGIST
Credential: PHD
Phone: 701-260-0713