1174375927 NPI number — MELISSA ANN KETTERL LBSW

Table of content: MELISSA ANN KETTERL LBSW (NPI 1174375927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174375927 NPI number — MELISSA ANN KETTERL LBSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTERL
Provider First Name:
MELISSA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LBSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEKANDER
Provider Other First Name:
MISSY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LBSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174375927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58045-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 W. CALEDONIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58045-0190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-636-5220
Provider Business Practice Location Address Fax Number:
701-636-5221
Provider Enumeration Date:
04/04/2024

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: 171M00000X , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1467934 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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