Organization
LAKEVILLE FAMILY THERAPY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATHLEEN MARIE KELLY MSW, LICSW (OWNER)
(612) 750-0263
Entity
Organization
Contact information
Practice address
17595 KENWOOD TRL, SUITE 210, LAKEVILLE, MN 55044-9226
(612) 750-0263
Mailing address
17595 KENWOOD TRL, SUITE 210, LAKEVILLE, MN 55044-9226
(612) 750-0263
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
19327
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1972800753
—
MN
Enumeration date
03/04/2013
Last updated
03/04/2013
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