Healthcare Provider Details

I. General information

NPI: 1033849591
Provider Name (Legal Business Name): ALYSHA KVAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12918 63RD AVE N
MAPLE GROVE MN
55369-6001
US

IV. Provider business mailing address

7200 WILLOW DR
CORCORAN MN
55340-9717
US

V. Phone/Fax

Practice location:
  • Phone: 763-210-9966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: