Healthcare Provider Details

I. General information

NPI: 1700972320
Provider Name (Legal Business Name): ANGELA ANN LUMBAR PSYD,LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELA ANN KENNEDY

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/18/2023
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 LITCHFIELD AVE SE
WILLMAR MN
56201-3476
US

IV. Provider business mailing address

PO BOX 396
FAIRFAX MN
55332-0361
US

V. Phone/Fax

Practice location:
  • Phone: 203-522-1411
  • Fax:
Mailing address:
  • Phone: 320-522-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP4330
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP4330
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberLP4330
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4330
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberLP4330
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP4330
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP4330
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: