Healthcare Provider Details

I. General information

NPI: 1407212806
Provider Name (Legal Business Name): KELLI P SKOOG M.A., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 GRAND AVE
SAINT PAUL MN
55105-2628
US

IV. Provider business mailing address

6712 2ND AVE S
RICHFIELD MN
55423-2411
US

V. Phone/Fax

Practice location:
  • Phone: 612-444-1890
  • Fax:
Mailing address:
  • Phone: 612-581-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3416
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberZ096253359215
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: