Provider Demographics
NPI:1437537750
Name:DUTTENHEFER, KYA
Entity Type:Individual
Prefix:
First Name:KYA
Middle Name:
Last Name:DUTTENHEFER
Suffix:
Gender:F
Credentials:
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 9859
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:651-925-0057
Practice Address - Street 1:815 37TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5524
Practice Address - Country:US
Practice Address - Phone:701-451-4811
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3207106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist