Healthcare Provider Details

I. General information

NPI: 1194297390
Provider Name (Legal Business Name): KATHY CLARK DANSBERRY LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2738 WINNETKA AVE N # 150M2
NEW HOPE MN
55427-2850
US

IV. Provider business mailing address

4425 RHODE ISLAND AVE N APT 324
NEW HOPE MN
55428-4942
US

V. Phone/Fax

Practice location:
  • Phone: 763-762-8728
  • Fax: 763-762-8762
Mailing address:
  • Phone: 763-710-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number300889
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: