Healthcare Provider Details

I. General information

NPI: 1073440616
Provider Name (Legal Business Name): SUZANNE KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 N FERRY ST
ANOKA MN
55303-1650
US

IV. Provider business mailing address

2727 N FERRY ST
ANOKA MN
55303-1650
US

V. Phone/Fax

Practice location:
  • Phone: 763-506-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0347092
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: