Provider Demographics
NPI:1386884450
Name:GOLDBERG-REISTAD, KYRSTEN LESLIE (LAC)
Entity type:Individual
Prefix:MRS
First Name:KYRSTEN
Middle Name:LESLIE
Last Name:GOLDBERG-REISTAD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 TALON WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-9352
Mailing Address - Country:US
Mailing Address - Phone:406-570-9407
Mailing Address - Fax:
Practice Address - Street 1:2417 WEST MAIN ST. SUITE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5971
Practice Address - Country:US
Practice Address - Phone:406-570-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT168171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist