Healthcare Provider Details

I. General information

NPI: 1235804113
Provider Name (Legal Business Name): KELLIE C BERNAL DELGADO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9298 CENTRAL AVE NE STE 310
BLAINE MN
55434-4219
US

IV. Provider business mailing address

9298 CENTRAL AVE NE STE 310
BLAINE MN
55434-4219
US

V. Phone/Fax

Practice location:
  • Phone: 651-955-4633
  • Fax: 651-440-9827
Mailing address:
  • Phone: 651-955-4633
  • Fax: 651-440-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27288
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: