Healthcare Provider Details

I. General information

NPI: 1316485634
Provider Name (Legal Business Name): THERESA E SCULLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MAIN ST; UNIT 220
WILLISTON ND
58801
US

IV. Provider business mailing address

125 MAIN ST UNIT 220
WILLISTON ND
58801-6030
US

V. Phone/Fax

Practice location:
  • Phone: 701-570-4602
  • Fax:
Mailing address:
  • Phone: 701-570-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4970
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: