Basic Information
| Provider Information | |||||||||
| NPI: | 1386002905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLSON | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSED, LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | KAYLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MSED, LPCC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186245683 | ||||||||
| FaxNumber: | 2186245736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1165 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.