MEDICARE: KALEIDOSCOPE COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305S00000X	Point of Service	3352	MN

General Provider Information

NPI Number	:	1295260412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEIDOSCOPE COUNSELING

Provider Business Mailing Address
First Line	:	3329 COLFAX AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3508
Country	:	US
Telephone Number	:	612-220-1642
Fax Number	:

Provider Business Practice Location Address
First Line	:	5871 CEDAR LAKE RD S
Second Line	:	SUITE 210
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-1472
Country	:	US
Telephone Number	:	612-220-1642
Fax Number	:

Authorized Official
Title or Position	:	CHILD DEV. CONSULTANT AND LAMFT
Name	:	MICHELLE SUAREZ
Credential	:
Telephone Number	:	612-220-1642

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	04/25/2017

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