Provider Demographics
NPI:1144554296
Name:HAMILTON, SHANE (CSW-PIP)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:CSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:6101 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-312-8000
Practice Address - Fax:605-312-8001
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD31401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1144554296Medicaid
SD1144554296Medicaid
SD1144554296Medicaid