Provider Demographics
NPI:1073001889
Name:BENNETT, KALLIE JOY
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:JOY
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:JOY
Other - Last Name:TRUTNAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 4TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1220
Mailing Address - Country:US
Mailing Address - Phone:952-496-8481
Mailing Address - Fax:
Practice Address - Street 1:14301 EWING AVE S
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-4885
Practice Address - Country:US
Practice Address - Phone:952-746-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN283611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty