Provider Demographics
NPI:1578975173
Name:KAUTZMAN, KARISSA MARIE (LAPC)
Entity Type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:MARIE
Last Name:KAUTZMAN
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:MRS
Other - First Name:KARISSA
Other - Middle Name:MARIE
Other - Last Name:BAUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-222-0386
Mailing Address - Fax:701-751-5705
Practice Address - Street 1:101 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-222-0386
Practice Address - Fax:701-751-5705
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1727101YA0400X
ND1204-6-15-22A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3000Medicaid