Provider Demographics
NPI:1184178782
Name:COOPER-SWENSON, KELLY (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COOPER-SWENSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-379-1718
Mailing Address - Fax:
Practice Address - Street 1:16201 90TH ST NE STE 200
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-7464
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health