Healthcare Provider Details

I. General information

NPI: 1780165415
Provider Name (Legal Business Name): KALEIDOSCOPE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 2ND ST W STE B
WILLISTON ND
58801-5907
US

IV. Provider business mailing address

511 2ND ST W STE B
WILLISTON ND
58801-5907
US

V. Phone/Fax

Practice location:
  • Phone: 701-580-0846
  • Fax:
Mailing address:
  • Phone: 701-580-0846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4168
License Number StateND

VIII. Authorized Official

Name: SARAH ANDERSON
Title or Position: THERAPIST
Credential: LICSW
Phone: 701-580-0846