Basic Information
| Provider Information | |||||||||
| NPI: | 1295765733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERTLER | ||||||||
| FirstName: | CHRIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277500 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277500 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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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 | 103T00000X | 229 | ND | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 005112 | 01 | ND | BC/BS PIN | OTHER | 54523 | 05 | ND | MEDICAID | 680009655 | 01 | RR MEDICARE PIN | OTHER |