Basic Information
| Provider Information | |||||||||
| NPI: | 1679645360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATES | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 CIRCLE DR SE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012533650 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2605 CIRCLE DR SE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012533650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1396 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 019170 | 01 | ND | BCBS PROVIDER NUMBER | OTHER |