Healthcare Provider Details

I. General information

NPI: 1144075722
Provider Name (Legal Business Name): KELSI DYBEDAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 8TH ST S STE 200
MOORHEAD MN
56560-4200
US

IV. Provider business mailing address

131 5TH AVE SE
MAYVILLE ND
58257-1431
US

V. Phone/Fax

Practice location:
  • Phone: 218-382-1267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: