Healthcare Provider Details

I. General information

NPI: 1891611596
Provider Name (Legal Business Name): KELLIE YANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 LIVINGSTON AVE STE 200
WEST ST PAUL MN
55118-3426
US

IV. Provider business mailing address

1160 FROST AVE APT 121
MAPLEWOOD MN
55109-0029
US

V. Phone/Fax

Practice location:
  • Phone: 651-313-8080
  • Fax: 651-925-0610
Mailing address:
  • Phone: 612-298-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: