Provider Demographics
NPI:1871608570
Name:RIVINIUS, SANDRA L (LAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:RIVINIUS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:L
Other - Last Name:RADERMACHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2605 CIRCLE DR SE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401
Mailing Address - Country:US
Mailing Address - Phone:701-253-3650
Mailing Address - Fax:
Practice Address - Street 1:2605 CIRCLE DR SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401
Practice Address - Country:US
Practice Address - Phone:701-253-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1477101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND027090OtherBCBS PROVIDER NUMBER