Healthcare Provider Details

I. General information

NPI: 1619601945
Provider Name (Legal Business Name): KELLY ZWICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 WASHINGTON ST
MONTICELLO MN
55362-8815
US

IV. Provider business mailing address

12245 COUNTY ROAD 3
CLEAR LAKE MN
55319-4730
US

V. Phone/Fax

Practice location:
  • Phone: 763-271-5340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC03232
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: