Provider Demographics
NPI:1235412388
Name:SHAREHOUSE MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:SHAREHOUSE MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TYREL
Authorized Official - Middle Name:
Authorized Official - Last Name:HEGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-282-6561
Mailing Address - Street 1:4227 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2018
Mailing Address - Country:US
Mailing Address - Phone:701-282-6561
Mailing Address - Fax:651-925-0046
Practice Address - Street 1:505 40TH ST S UNIT A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1184
Practice Address - Country:US
Practice Address - Phone:701-478-8440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAREHOUSE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-26
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1056251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health