Healthcare Provider Details

I. General information

NPI: 1417801820
Provider Name (Legal Business Name): HEATHER KOSTOHRYZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER BEESON

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 37TH AVE S
MOORHEAD MN
56560-5524
US

IV. Provider business mailing address

2701 12TH AVE S
FARGO ND
58103-8753
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-4811
  • Fax: 651-925-0057
Mailing address:
  • Phone: 701-451-4900
  • Fax: 651-925-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1521-1-15-26A
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3267
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: