1467878728 NPI number — KELLY JO HAWSEN MA, LPC

Table of content: KELLY JO HAWSEN MA, LPC (NPI 1467878728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467878728 NPI number — KELLY JO HAWSEN MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAWSEN
Provider First Name:
KELLY
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467878728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND MARAIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55604-0283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-370-8773
Provider Business Mailing Address Fax Number:
218-387-2248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 W HIGHWAY 61
Provider Second Line Business Practice Location Address:
BOX 283
Provider Business Practice Location Address City Name:
GRAND MARAIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55604-7508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-370-8773
Provider Business Practice Location Address Fax Number:
218-387-2248
Provider Enumeration Date:
03/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  00785 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1629482112 . This is a "STEPS OF CHANGE LLC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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