Healthcare Provider Details

I. General information

NPI: 1629566583
Provider Name (Legal Business Name): SADIE PAMELA KIESON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 UNIVERSITY AVE
WILLISTON ND
58801-5658
US

IV. Provider business mailing address

222 UNIVERSITY AVE
WILLISTON ND
58801-5658
US

V. Phone/Fax

Practice location:
  • Phone: 701-421-7640
  • Fax:
Mailing address:
  • Phone: 701-444-3661
  • Fax: 701-444-6436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6331
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: