Healthcare Provider Details

I. General information

NPI: 1215562921
Provider Name (Legal Business Name): KIM SURVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LONG LAKE RD STE 320
NEW BRIGHTON MN
55112-6439
US

IV. Provider business mailing address

786 CANNON AVE
SHOREVIEW MN
55126-3827
US

V. Phone/Fax

Practice location:
  • Phone: 651-482-9361
  • Fax:
Mailing address:
  • Phone: 612-396-8305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY SURVE
Title or Position: MANAGER
Credential: MA LMFT
Phone: 612-396-8305