Healthcare Provider Details

I. General information

NPI: 1194034579
Provider Name (Legal Business Name): MANDIE BOLTON KENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 LIVINGSTON AVE
WEST SAINT PAUL MN
55118-3912
US

IV. Provider business mailing address

11 MARQUETTE AVE #601
MINNEAPOLIS MN
55401
US

V. Phone/Fax

Practice location:
  • Phone: 651-457-2248
  • Fax:
Mailing address:
  • Phone: 612-232-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number179584
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: