Provider Demographics
NPI:1083658165
Name:DELANEY, PHILLIP (LAC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:DELANEY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-0650
Mailing Address - Country:US
Mailing Address - Phone:701-665-2200
Mailing Address - Fax:701-665-2300
Practice Address - Street 1:200 HIGHWAY 2 W
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3532
Practice Address - Country:US
Practice Address - Phone:701-665-2200
Practice Address - Fax:701-665-2300
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND054518Medicaid
ND023521OtherBCBS PIN