MEDICARE: STACY JO SOMMERVOLD PSY.D.

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	103TC0700X	Clinical Psychologist	609	SD

General Provider Information

NPI Number	:	1780372847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY JO SOMMERVOLD PSY.D.

Provider Business Mailing Address
First Line	:	7412 E SHADOW PINE CIR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-6332
Country	:	US
Telephone Number	:	304-906-6874
Fax Number	:

Provider Business Practice Location Address
First Line	:	7412 E SHADOW PINE CIR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-6332
Country	:	US
Telephone Number	:	304-906-6874
Fax Number	:

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

Provider Enumeration Date	:	04/26/2023
Last Update Date	:	04/26/2023

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