Provider Demographics
NPI:1760765416
Name:PYTLIK, ROBERTA J (LAC, LPCC)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:PYTLIK
Suffix:
Gender:F
Credentials:LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 57TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5720
Mailing Address - Country:US
Mailing Address - Phone:701-793-5400
Mailing Address - Fax:
Practice Address - Street 1:17 7TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1800
Practice Address - Country:US
Practice Address - Phone:701-478-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND873-4-15-16-365101YP2500X
ND1659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional