Healthcare Provider Details

I. General information

NPI: 1295212355
Provider Name (Legal Business Name): KESMA FLAME LILY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2018
Last Update Date: 09/06/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7030 BROOKLYN BLVD STE 2047
BROOKLYN CENTER MN
55429-1370
US

IV. Provider business mailing address

20705 OTERO AVE
HASTINGS MN
55033-9600
US

V. Phone/Fax

Practice location:
  • Phone: 612-408-7733
  • Fax: 763-292-5653
Mailing address:
  • Phone: 612-408-7733
  • Fax: 763-292-5653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETRONELLAH THOKO BENSEN
Title or Position: CEO/CLINICAL DIRECTOR
Credential: LPCC
Phone: 612-408-7733