Provider Demographics
NPI:1366907545
Name:KAREN J. KIETZMAN. PSY.D., INC.
Entity type:Organization
Organization Name:KAREN J. KIETZMAN. PSY.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIETZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:406-248-4153
Mailing Address - Street 1:2475 VILLAGE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-2497
Mailing Address - Country:US
Mailing Address - Phone:406-248-4153
Mailing Address - Fax:
Practice Address - Street 1:2475 VILLAGE LN STE 104
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-2497
Practice Address - Country:US
Practice Address - Phone:406-248-4153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT103T00000XMedicaid