Healthcare Provider Details

I. General information

NPI: 1841698339
Provider Name (Legal Business Name): KINGDOM IN ACTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2014
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MINNETONKA BLVD
ST LOUIS PARK MN
55426-2944
US

IV. Provider business mailing address

9500 MINNETONKA BLVD
ST LOUIS PARK MN
55426-2944
US

V. Phone/Fax

Practice location:
  • Phone: 952-933-4808
  • Fax:
Mailing address:
  • Phone: 952-933-4808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1075563-2-CDT
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1075563-2-CDT
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1075563-2-CDT
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number1075563-2-CDT
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number1075563-2-CDT
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1075563-2-CDT
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1075563-2-CDT
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number1075563
License Number StateMN

VIII. Authorized Official

Name: REGINALD FITZGERALD LEWIS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 952-933-4808