Healthcare Provider Details

I. General information

NPI: 1306014162
Provider Name (Legal Business Name): KELLY CAMERON LINDBERG LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY CAMERON SMITH LACD

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 WASHINGTON ST
MONTICELLO MN
55362-8815
US

IV. Provider business mailing address

407 WASHINGTON ST
MONTICELLO MN
55362-8815
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-4001
  • Fax: 763-295-5086
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302082
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: