Provider Demographics
NPI:1417953951
Name:RADER, SHIRLEY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:J
Last Name:RADER
Suffix:
Gender:F
Credentials:PHD
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 1594
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-1594
Mailing Address - Country:US
Mailing Address - Phone:218-847-5401
Mailing Address - Fax:218-573-2350
Practice Address - Street 1:801 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3703
Practice Address - Country:US
Practice Address - Phone:218-847-5401
Practice Address - Fax:218-573-2350
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3342103TC1900X
ND320103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19698RADOtherND BLUE CROSS BLUE SHIELD
MN01019338OtherPREFERRED ONE PROVIDER #
MN6G302RAOtherMN BLUE CROSS BLUE SHIELD
ND10857Medicaid