=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033949128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REALATIONAL THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2024
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 W BEATON DR SUITE 100
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-2652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-347-1648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3846 12TH ST W
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-8164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-260-9713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEIDI LECKNER
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 701-260-9713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------