Healthcare Provider Details

I. General information

NPI: 1710442017
Provider Name (Legal Business Name): BLACK HILLS CENTER FOR HEALING AND ADVANCEMENT OF PSYCHOTHERAPY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W MAIN ST STE 303A6
RAPID CITY SD
57702-2437
US

IV. Provider business mailing address

2525 W MAIN ST STE 303A6
RAPID CITY SD
57702-2437
US

V. Phone/Fax

Practice location:
  • Phone: 605-440-2287
  • Fax: 605-791-2086
Mailing address:
  • Phone: 605-440-2287
  • Fax: 605-791-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier2013208
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: ELIZABETH OSTOLOZAGA
Title or Position: OWNER
Credential: LCSW-PIP
Phone: 605-440-2287