Provider Demographics
NPI:1366724643
Name:REICHENBERG, KATHLEEN ELIZABETH (LAC)
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:REICHENBERG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:REICHENBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPCC
Mailing Address - Street 1:722 N MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:WATFORD CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58854-7354
Mailing Address - Country:US
Mailing Address - Phone:701-444-3979
Mailing Address - Fax:701-444-3944
Practice Address - Street 1:722 N MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:WATFORD CITY
Practice Address - State:ND
Practice Address - Zip Code:58854-7354
Practice Address - Country:US
Practice Address - Phone:701-444-3979
Practice Address - Fax:701-444-3944
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND941-3-18A101YM0800X
ND1646101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND941-3-18AMedicaid