Provider Demographics
NPI:1356739551
Name:SPICZKA, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SPICZKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPCC
Mailing Address - Street 1:1351 PAGE DR S STE 301
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3536
Mailing Address - Country:US
Mailing Address - Phone:701-205-4533
Mailing Address - Fax:701-205-4593
Practice Address - Street 1:1351 PAGE DR S STE 301
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-205-4533
Practice Address - Fax:701-205-4593
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND811-12-1-14A101YP2500X
ND811-12-1-14-296101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional