Provider Demographics
NPI:1306014162
Name:LINDBERG, KELLY CAMERON (LADC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CAMERON
Last Name:LINDBERG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:CAMERON
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LACD
Mailing Address - Street 1:407 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8815
Practice Address - Country:US
Practice Address - Phone:763-295-4001
Practice Address - Fax:763-295-5086
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302082101YA0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302082OtherLADC