Provider Demographics
NPI:1619635653
Name:MOCH, SHELBY C
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:C
Last Name:MOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6221
Mailing Address - Country:US
Mailing Address - Phone:702-232-2452
Mailing Address - Fax:701-298-3115
Practice Address - Street 1:3233 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-6221
Practice Address - Country:US
Practice Address - Phone:702-232-2452
Practice Address - Fax:701-298-3115
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
ND6109104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist