Healthcare Provider Details

I. General information

NPI: 1881181642
Provider Name (Legal Business Name): NORTHERN HILLS PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 N MAIN ST STE 1
SPEARFISH SD
57783-3017
US

IV. Provider business mailing address

1130 N MAIN ST STE 1
SPEARFISH SD
57783-3017
US

V. Phone/Fax

Practice location:
  • Phone: 605-641-8880
  • Fax:
Mailing address:
  • Phone: 605-641-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number530
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number530
License Number StateSD

VIII. Authorized Official

Name: SHANNON JEAN MAXWELL
Title or Position: OWNER
Credential: PSY.D
Phone: 605-641-8880