1871805614 NPI number — BRITT NICOLE SHACKELFORD WESSEL PSYD, LP

Table of content: BRITT NICOLE SHACKELFORD WESSEL PSYD, LP (NPI 1871805614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871805614 NPI number — BRITT NICOLE SHACKELFORD WESSEL PSYD, LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESSEL
Provider First Name:
BRITT
Provider Middle Name:
NICOLE SHACKELFORD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD, LP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHACKELFORD
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD, LP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1871805614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3503 HIGH POINT DRIVE N
Provider Second Line Business Mailing Address:
BLDG 3, SUITE 230
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55128-6158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-787-7050
Provider Business Mailing Address Fax Number:
612-844-2784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3503 HIGH POINT DRIVE N
Provider Second Line Business Practice Location Address:
BLDG 3, SUITE 230
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55128-6158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-787-7050
Provider Business Practice Location Address Fax Number:
612-844-2784
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP5297 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 301108000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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