Provider Demographics
NPI:1255125761
Name:HETTICH, KODI LYNN (MS, LAPC)
Entity type:Individual
Prefix:
First Name:KODI
Middle Name:LYNN
Last Name:HETTICH
Suffix:
Gender:F
Credentials:MS, LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 1/2 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4149
Mailing Address - Country:US
Mailing Address - Phone:701-390-4542
Mailing Address - Fax:
Practice Address - Street 1:623 1/2 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4149
Practice Address - Country:US
Practice Address - Phone:701-390-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1431-4-1-25A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health