Provider Demographics
NPI:1447748918
Name:CHRYSALIS BEHAVIORAL HEALTH SERVICES AND TRAINING CENTER
Entity Type:Organization
Organization Name:CHRYSALIS BEHAVIORAL HEALTH SERVICES AND TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR, PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAVETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-260-0713
Mailing Address - Street 1:102 W BEATON DR STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2653
Mailing Address - Country:US
Mailing Address - Phone:701-260-0713
Mailing Address - Fax:701-356-4940
Practice Address - Street 1:1620 16TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4055
Practice Address - Country:US
Practice Address - Phone:701-260-0713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty