Healthcare Provider Details

I. General information

NPI: 1972262780
Provider Name (Legal Business Name): CATHERINE REVERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 16TH ST W STE 300
WILLISTON ND
58801-3888
US

IV. Provider business mailing address

1542 16TH ST W STE 300
WILLISTON ND
58801-3888
US

V. Phone/Fax

Practice location:
  • Phone: 701-200-8113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6148
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: