Provider Demographics
NPI:1710795463
Name:PALMER, KATRENA DEZERAI (LAC)
Entity type:Individual
Prefix:
First Name:KATRENA
Middle Name:DEZERAI
Last Name:PALMER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1530
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-1530
Mailing Address - Country:US
Mailing Address - Phone:406-234-0234
Mailing Address - Fax:406-234-0235
Practice Address - Street 1:130 3RD ST S
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:MT
Practice Address - Zip Code:59230-2303
Practice Address - Country:US
Practice Address - Phone:406-228-9349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT71830OtherLAC LICENSE