Healthcare Provider Details

I. General information

NPI: 1407344286
Provider Name (Legal Business Name): CHARLIE RAY HYSTAD-MOE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 01/11/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 1ST AVE W STE 4
WILLISTON ND
58801-6286
US

IV. Provider business mailing address

2224 1ST AVE W STE 4
WILLISTON ND
58801-6286
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-3335
  • Fax: 701-572-3337
Mailing address:
  • Phone: 701-572-3335
  • Fax: 701-572-3337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5334
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: