Healthcare Provider Details

I. General information

NPI: 1194653691
Provider Name (Legal Business Name): MAEDELIN KELLY LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 COUNTY ROAD 101 STE 300
MINNETONKA MN
55345-4157
US

IV. Provider business mailing address

9401 NORWOOD LN N STE 300
MAPLE GROVE MN
55369-7147
US

V. Phone/Fax

Practice location:
  • Phone: 952-932-7277
  • Fax: 952-932-9827
Mailing address:
  • Phone: 763-370-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5585
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: