Provider Demographics
NPI:1114476660
Name:QUIST, LORI (MA, LADC)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:QUIST
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29207 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-8516
Mailing Address - Country:US
Mailing Address - Phone:612-250-1679
Mailing Address - Fax:
Practice Address - Street 1:555 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-1175
Practice Address - Country:US
Practice Address - Phone:651-251-5225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303276101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)