Provider Demographics
NPI:1912440256
Name:HALBUR/WITHAM, LLC
Entity Type:Organization
Organization Name:HALBUR/WITHAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:320-282-0112
Mailing Address - Street 1:65189 365TH ST
Mailing Address - Street 2:
Mailing Address - City:WATKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55389-6054
Mailing Address - Country:US
Mailing Address - Phone:320-224-1407
Mailing Address - Fax:
Practice Address - Street 1:2623 125TH ST NE
Practice Address - Street 2:
Practice Address - City:RICE
Practice Address - State:MN
Practice Address - Zip Code:56367-9746
Practice Address - Country:US
Practice Address - Phone:320-260-6755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106H00000X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization