Provider Demographics
NPI:1679669709
Name:HARTSON, KANDY M (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KANDY
Middle Name:M
Last Name:HARTSON
Suffix:
Gender:F
Credentials:LICSW
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 2027
Mailing Address - Street 2:510 4TH ST S PRAIRIE ST JOHNS HOSPITAL
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2027
Mailing Address - Country:US
Mailing Address - Phone:701-476-7200
Mailing Address - Fax:701-476-7263
Practice Address - Street 1:510 4TH STREET SOUTH
Practice Address - Street 2:PRAIRIE ST JOHNS HOSPITAL
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58107-2027
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:701-476-7263
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN09579101YM0800X
ND8491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19121Medicaid
ND19121Medicaid