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General NPI Number Information
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NPI Number | 1912788357
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Entity Type | Organization
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Legal Business Name | PRAIRIE RIVER THERAPY AND ASSESSMENTS
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Dates
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Enumeration Date | 10/11/2023
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 3710 26TH ST W APT 3304
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City | WILLISTON
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State | ND
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Zip | 58801-5373
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Country | US
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Telephone | 801-717-0405
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Fax |
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Provider Business Mailing Address
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Address Line | 3710 26TH ST W APT 3304
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City | WILLISTON
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State | ND
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Zip | 58801-5373
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Country | US
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Telephone | 801-717-0405
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. BRENNAN DALE ATHERTON
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Credential | PHD
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Telephone | 801-717-0405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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