Provider Demographics
NPI:1932697885
Name:BERQUIST, BAILEY
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BERQUIST
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 1:2220 35TH ST NW APT 101
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-5017
Mailing Address - Country:US
Mailing Address - Phone:701-570-6401
Mailing Address - Fax:
Practice Address - Street 1:900 N BROADWAY
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2300
Practice Address - Country:US
Practice Address - Phone:701-833-1246
Practice Address - Fax:701-335-7106
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1307-6-15-23A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460241Medicaid