Provider Demographics
NPI:1346420643
Name:KELLY, BIRGIT OLSEN (LICSW)
Entity Type:Individual
Prefix:
First Name:BIRGIT
Middle Name:OLSEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8990 SPRINGBROOK DR NW
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5850
Mailing Address - Country:US
Mailing Address - Phone:763-780-4440
Mailing Address - Fax:763-780-9219
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:SUITE 220
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-780-4440
Practice Address - Fax:763-780-9219
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical