Healthcare Provider Details

I. General information

NPI: 1427618446
Provider Name (Legal Business Name): HEATHER KIPPEN, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 22ND AVE NW STE 1
MINOT ND
58703-0986
US

IV. Provider business mailing address

600 22ND AVE NW STE 1
MINOT ND
58703-0986
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-3909
  • Fax: 701-839-9071
Mailing address:
  • Phone: 701-839-3909
  • Fax: 701-839-9071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1462801
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier1477897
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: HEATHER D KIPPEN
Title or Position: INDIVIDUAL/FAMILY THERAPIST
Credential: LCSW
Phone: 701-839-3909