Provider Demographics
NPI:1609964238
Name:NYBERG, ROCHELLE RENEE (LICSW)
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:RENEE
Last Name:NYBERG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 BURDICK EXPY W
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-5667
Mailing Address - Country:US
Mailing Address - Phone:701-852-7171
Mailing Address - Fax:701-852-7121
Practice Address - Street 1:1821 BURDICK EXPY W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-5667
Practice Address - Country:US
Practice Address - Phone:701-852-7171
Practice Address - Fax:701-852-7121
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND32541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND030078OtherBLUE CROSS BLUE SHIELD
ND54517Medicaid
ND030078OtherBLUE CROSS BLUE SHIELD