Healthcare Provider Details

I. General information

NPI: 1912106600
Provider Name (Legal Business Name): ASHLEY MARIE KOTTSICK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 4TH AVE NE
LAMOURE ND
58458
US

IV. Provider business mailing address

202 4TH AVE NE PO BOX 38
LAMOURE ND
58458
US

V. Phone/Fax

Practice location:
  • Phone: 701-883-6068
  • Fax: 701-883-4427
Mailing address:
  • Phone: 701-883-6068
  • Fax: 701-883-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4111
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: