Basic Information
Provider Information | |||||||||
NPI: | 1467636720 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IVANETS | ||||||||
FirstName: | LOREE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LAC, NCAC II | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BASARABA | ||||||||
OtherFirstName: | LOREE | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1463 I94 BUSINESS LOOP E | ||||||||
Address2: |   | ||||||||
City: | DICKINSON | ||||||||
State: | ND | ||||||||
PostalCode: | 586016434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012277500 | ||||||||
FaxNumber: | 7012277575 | ||||||||
Practice Location | |||||||||
Address1: | 1463 I94 BUSINESS LOOP E | ||||||||
Address2: |   | ||||||||
City: | DICKINSON | ||||||||
State: | ND | ||||||||
PostalCode: | 586016434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012277500 | ||||||||
FaxNumber: | 7012277575 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2007 | ||||||||
LastUpdateDate: | 12/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 174400000X |   |   | N |   | Other Service Providers | Specialist |   | 101YA0400X | 1340 | ND | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.