Healthcare Provider Details

I. General information

NPI: 1457218216
Provider Name (Legal Business Name): CALDERA THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5598 145TH AVE NW
WILLISTON ND
58801-9033
US

IV. Provider business mailing address

5598 145TH AVE NW
WILLISTON ND
58801-9033
US

V. Phone/Fax

Practice location:
  • Phone: 701-570-4027
  • Fax:
Mailing address:
  • Phone: 701-570-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHARLIE RAY HYSTAD-MOE
Title or Position: MENTAL HEALTH THERAPIST
Credential: LAC, LCSW
Phone: 701-570-4027