=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114431558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAILA PARK LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3033 EXCELSIOR BLVD STE 215
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-5274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-456-8396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2715 LONGACRES DR
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-7557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-458-5756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 01887
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------