Basic Information
| Provider Information | |||||||||
| NPI: | 1982711867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMOLEN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1463 I94 BUSINESS LOOP E | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586016434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277000 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1463 I94 BUSINESS LOOP E | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586016434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277000 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 54523 | 05 | ND | MEDICAID |