Healthcare Provider Details

I. General information

NPI: 1801337415
Provider Name (Legal Business Name): SELAH COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MAIN ST, SUITE #220
WILLISTON ND
58801
US

IV. Provider business mailing address

PO BOX 1883
WILLISTON ND
58802-1883
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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4970
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number4970
License Number StateND

VIII. Authorized Official

Name: THERESA E SCULLY
Title or Position: OWNER/PRACTIONER
Credential: MSW, LICSW
Phone: 701-570-4602