Provider Demographics
NPI:1255667903
Name:KLEVESAHL, KATHLEEN NORTH (LADC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NORTH
Last Name:KLEVESAHL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15198 LESLEY LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-2533
Mailing Address - Country:US
Mailing Address - Phone:952-934-7300
Mailing Address - Fax:
Practice Address - Street 1:4432 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3519
Practice Address - Country:US
Practice Address - Phone:612-870-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301930101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)