Healthcare Provider Details

I. General information

NPI: 1396329686
Provider Name (Legal Business Name): KATHRYN COTTRELL DUSEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4804 THOMAS AVE S
MINNEAPOLIS MN
55410-1802
US

IV. Provider business mailing address

4804 THOMAS AVE S
MINNEAPOLIS MN
55410-1802
US

V. Phone/Fax

Practice location:
  • Phone: 617-519-8083
  • Fax:
Mailing address:
  • Phone: 617-519-8083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number460940345
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: