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General NPI Number Information
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NPI Number | 1457218216
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Entity Type | Organization
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Legal Business Name | CALDERA THERAPY, PLLC
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Dates
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Enumeration Date | 01/05/2026
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Last Update Date | 01/05/2026
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Provider Practice Location Address
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Address Line | 5598 145TH AVE NW
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City | WILLISTON
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State | ND
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Zip | 58801-9033
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Country | US
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Telephone | 701-570-4027
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Fax |
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Provider Business Mailing Address
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Address Line | 5598 145TH AVE NW
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City | WILLISTON
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State | ND
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Zip | 58801-9033
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Country | US
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Telephone | 701-570-4027
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | CHARLIE RAY HYSTAD-MOE
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Credential | LAC, LCSW
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Telephone | 701-570-4027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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