Healthcare Provider Details

I. General information

NPI: 1174707566
Provider Name (Legal Business Name): COLETTE CLARICE KUZNIA MED MASTERS DEGREE I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 CENTER AVE SUITE 405
MOORHEAD MN
56560
US

IV. Provider business mailing address

403 CENTER AVE SUITE 405 COLETTE C KUZNIA
MOORHEAD MN
56560
US

V. Phone/Fax

Practice location:
  • Phone: 218-233-9426
  • Fax:
Mailing address:
  • Phone: 218-233-9426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00117
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number25811117
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number30474
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: