Provider Demographics
NPI:1316567886
Name:HAVLICEK, KESENYA
Entity Type:Individual
Prefix:
First Name:KESENYA
Middle Name:
Last Name:HAVLICEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 W 229TH ST
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-9459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4040 RADIO DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-3237
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer