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General NPI Number Information
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NPI Number | 1114268943
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Entity Type | Organization
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Legal Business Name | LAKEVILLE FAMILY THERAPY
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Dates
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Enumeration Date | 03/04/2013
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Last Update Date | 03/04/2013
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Provider Practice Location Address
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Address Line | 17595 KENWOOD TRL SUITE 210
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City | LAKEVILLE
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State | MN
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Zip | 55044-9226
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Country | US
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Telephone | 612-750-0263
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Fax |
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Provider Business Mailing Address
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Address Line | 17595 KENWOOD TRL SUITE 210
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City | LAKEVILLE
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State | MN
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Zip | 55044-9226
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Country | US
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Telephone | 612-750-0263
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KATHLEEN MARIE KELLY
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Credential | MSW, LICSW
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Telephone | 612-750-0263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 19327
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License Number State | MN
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