Provider Demographics
NPI:1013269257
Name:CARITA R SHAWCHUCK, PHD, PC
Entity Type:Organization
Organization Name:CARITA R SHAWCHUCK, PHD, PC
Other - Org Name:CHILD AND FAMILY THERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARITA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAWCHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-893-3419
Mailing Address - Street 1:1121 WESTRAC DR S STE 204
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2385
Mailing Address - Country:US
Mailing Address - Phone:701-893-3419
Mailing Address - Fax:701-356-8801
Practice Address - Street 1:1121 WESTRAC DR S STE 204
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2385
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:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND295103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11062Medicaid