Healthcare Provider Details

I. General information

NPI: 1306420310
Provider Name (Legal Business Name): KEITH WARREN MUNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 OLEARY LN
EAGAN MN
55123-2340
US

IV. Provider business mailing address

3109 201ST ST W
FARMINGTON MN
55024-9346
US

V. Phone/Fax

Practice location:
  • Phone: 651-365-8523
  • Fax: 651-454-3492
Mailing address:
  • Phone: 651-269-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3565
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: