Provider Demographics
NPI:1144392481
Name:ZIEMANN, KEVYN DEWAYNE (LP)
Entity Type:Individual
Prefix:
First Name:KEVYN
Middle Name:DEWAYNE
Last Name:ZIEMANN
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 GREELEY ST S
Mailing Address - Street 2:SUITE 202C
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5097
Mailing Address - Country:US
Mailing Address - Phone:651-491-5602
Mailing Address - Fax:651-748-5773
Practice Address - Street 1:1940 GREELEY ST S
Practice Address - Street 2:SUITE 202C
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5097
Practice Address - Country:US
Practice Address - Phone:651-491-5602
Practice Address - Fax:651-748-5773
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4915103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN620000313Medicare PIN