=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164948741
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY CHRISTINA BRETSON MSW, LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2017
-----------------------------------------------------
Last Update Date | 08/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7066 STILLWATER BLVD N
-----------------------------------------------------
City | OAKDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55128-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-748-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1376 FURNESS PKWY
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55119-3275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------