Provider Demographics
NPI:1336115435
Name:HALL, SHELLY MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:MARIE
Last Name:HALL
Suffix:
Gender:F
Credentials:PSYD
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 810
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58602-0810
Mailing Address - Country:US
Mailing Address - Phone:701-264-9339
Mailing Address - Fax:
Practice Address - Street 1:30 -7TH ST. W, DOOR A
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-483-0230
Practice Address - Fax:701-483-0231
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND382103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26241OtherBLUE CROSS/BLUE SHIELD
ND1454557Medicaid
NDN711861Medicare PIN