Provider Demographics
NPI:1881181642
Name:NORTHERN HILLS PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:NORTHERN HILLS PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:605-641-8880
Mailing Address - Street 1:1130 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-3017
Mailing Address - Country:US
Mailing Address - Phone:605-641-8880
Mailing Address - Fax:
Practice Address - Street 1:1130 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3017
Practice Address - Country:US
Practice Address - Phone:605-641-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD530103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1881181642Medicaid