Basic Information
| Provider Information | |||||||||
| NPI: | 1891240867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERN | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 S FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550332684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125000905 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15650 CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551247283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2016 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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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 | 106H00000X | 3326 | MN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.