Healthcare Provider Details

I. General information

NPI: 1184534216
Provider Name (Legal Business Name): KEYANA NICOLE DONALD LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 4TH ST NE
COLUMBIA HEIGHTS MN
55421-2711
US

IV. Provider business mailing address

4241 4TH ST NE
COLUMBIA HEIGHTS MN
55421-2711
US

V. Phone/Fax

Practice location:
  • Phone: 612-757-0631
  • Fax:
Mailing address:
  • Phone: 612-757-0631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34461
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: