Healthcare Provider Details

I. General information

NPI: 1104892785
Provider Name (Legal Business Name): EILEEN SPELLACY LEIR CSW-PIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 EAST NEW YORK
RAPID CITY SD
57701-2441
US

IV. Provider business mailing address

PO BOX 9462
RAPID CITY SD
57709-9462
US

V. Phone/Fax

Practice location:
  • Phone: 605-342-0504
  • Fax: 605-348-0919
Mailing address:
  • Phone: 605-342-0504
  • Fax: 605-348-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1806
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9233748
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerDAKOTA CARE
# 2
Identifier6571040
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 3
Identifier4995473
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerBLUE CROSS/BLE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: