Healthcare Provider Details

I. General information

NPI: 1730709007
Provider Name (Legal Business Name): LISA JOY KLEIN-CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W JAMES ST
PAYNESVILLE MN
56362-1216
US

IV. Provider business mailing address

204 10TH AVE N
COLD SPRING MN
56320-1229
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-3379
  • Fax: 320-243-3138
Mailing address:
  • Phone: 320-291-1831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number302590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: