Healthcare Provider Details

I. General information

NPI: 1104152032
Provider Name (Legal Business Name): KELSEY ANN LANDIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 33RD AVE N STE 103
SAINT CLOUD MN
56303-1929
US

IV. Provider business mailing address

325 33RD AVE N STE 103
SAINT CLOUD MN
56303-1929
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-3715
  • Fax: 320-252-2567
Mailing address:
  • Phone: 320-253-3715
  • Fax: 320-252-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1742
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: