Provider Demographics
NPI:1366563215
Name:SANDBULTE INC
Entity type:Organization
Organization Name:SANDBULTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANDBULTE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LP
Authorized Official - Phone:605-332-1700
Mailing Address - Street 1:2210 W BROWN PLACE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105
Mailing Address - Country:US
Mailing Address - Phone:605-332-1700
Mailing Address - Fax:605-336-9031
Practice Address - Street 1:2210 W. BROWN PLACE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-332-1700
Practice Address - Fax:605-336-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD311103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550683Medicaid
SD0004659OtherBLUE CROSS BLUE SHIELD
SD6550683Medicaid
SD101001Medicare ID - Type UnspecifiedGROUP NUMBER