Provider Demographics
NPI:1730254418
Name:WEISZ, SHANNON PAUL (PSYD, LAC)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:PAUL
Last Name:WEISZ
Suffix:
Gender:M
Credentials:PSYD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N MANDAN ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3886
Mailing Address - Country:US
Mailing Address - Phone:701-323-0924
Mailing Address - Fax:701-323-0935
Practice Address - Street 1:309 N MANDAN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3886
Practice Address - Country:US
Practice Address - Phone:701-323-0924
Practice Address - Fax:701-323-0935
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND470103T00000X
ND1549101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17326Medicaid
ND17326Medicaid