Basic Information
| Provider Information | |||||||||
| NPI: | 1902912272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPOONER | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LAC, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2055 | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584022055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012536366 | ||||||||
| FaxNumber: | 7012536400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 FIECHTNER DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012933384 | ||||||||
| FaxNumber: | 6519250057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 11/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 2163 | ND | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 1358 | ND | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 011580 | 01 | ND | BCBS PROVIDER NUMBER | OTHER |