Healthcare Provider Details

I. General information

NPI: 1104901818
Provider Name (Legal Business Name): MANDY J BUICK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDY J VANHOVE

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W BROADWAY STE 202
WILLISTON ND
58801-6056
US

IV. Provider business mailing address

110 W BROADWAY STE 202
WILLISTON ND
58801-6056
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-6300
  • Fax:
Mailing address:
  • Phone: 701-774-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberBUI-81-0352
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3955
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: