Provider Demographics
NPI:1871650267
Name:CARITA R SHAWCHUCK PHD PC
Entity Type:Organization
Organization Name:CARITA R SHAWCHUCK PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARITA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SHAWCHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-893-3419
Mailing Address - Street 1:1351 PAGE DR S
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3502
Mailing Address - Country:US
Mailing Address - Phone:701-893-3419
Mailing Address - Fax:701-356-8801
Practice Address - Street 1:1351 PAGE DR S
Practice Address - Street 2:SUITE 105
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3502
Practice Address - Country:US
Practice Address - Phone:701-893-3419
Practice Address - Fax:701-356-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND06753001OtherND BLUE SHIELD
MN86G13SHOtherMN BLUE SHEILD