MEDICARE: DR. SHIRLEY J RADER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	LP3342	MN
2	103TC1900X	Counseling Psychologist	320	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19698RAD	OTHER	ND	ND BLUE CROSS BLUE SHIELD
2	01019338	OTHER	MN	PREFERRED ONE PROVIDER #
3	6G302RA	OTHER	MN	MN BLUE CROSS BLUE SHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417953951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHIRLEY J RADER PHD

Provider Business Mailing Address
First Line	:	PO BOX 1594
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56502-1594
Country	:	US
Telephone Number	:	218-847-5401
Fax Number	:	218-573-2350

Provider Business Practice Location Address
First Line	:	801 ROOSEVELT AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3703
Country	:	US
Telephone Number	:	218-847-5401
Fax Number	:	218-573-2350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	07/09/2007

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