Provider Demographics
NPI:1164479242
Name:DAHL, SHELLEY (MS)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:DAHL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3322
Mailing Address - Country:US
Mailing Address - Phone:218-329-6294
Mailing Address - Fax:888-816-9567
Practice Address - Street 1:820 4TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3322
Practice Address - Country:US
Practice Address - Phone:218-329-6294
Practice Address - Fax:888-816-9567
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1264106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN897300800Medicaid
MNHP56456OtherHEALTHPARTNERS
MN1044786OtherPREFERREDONE
MN137074OtherUCARE MINNESOTA
MN310P2DAOtherBLUE CROSS BLUE SHIELD
ND1466191Medicaid