MEDICARE: MS. KIMBERLEY MARIE EDENS LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	301386	MN

General Provider Information

NPI Number	:	1205955978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLEY MARIE EDENS LADC

Provider Business Mailing Address
First Line	:	763 2ND ST
Second Line	:
City	:	HAMMOND
State	:	WI
Zip	:	54015-9781
Country	:	US
Telephone Number	:	651-270-2123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 JACKSON ST NE
Second Line	:	SUITE 105
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1672
Country	:	US
Telephone Number	:	612-236-1705
Fax Number	:	612-236-1701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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