Healthcare Provider Details

I. General information

NPI: 1346568433
Provider Name (Legal Business Name): KRISTY LEE WALDEN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5095 FISH LAKE RD
DULUTH MN
55803-8433
US

IV. Provider business mailing address

114 S 20TH AVE W STE A
DULUTH MN
55806-3526
US

V. Phone/Fax

Practice location:
  • Phone: 218-733-1331
  • Fax: 218-733-0499
Mailing address:
  • Phone: 218-733-1331
  • Fax: 218-733-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13528
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: