Healthcare Provider Details

I. General information

NPI: 1255263950
Provider Name (Legal Business Name): KELLY WOMERSLEY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 INDIAN BLVD S
COTTAGE GROVE MN
55016-3603
US

IV. Provider business mailing address

7362 E POINT DOUGLAS RD S
COTTAGE GROVE MN
55016-3025
US

V. Phone/Fax

Practice location:
  • Phone: 651-425-4224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: