Provider Demographics
NPI:1346593365
Name:MARSH, KALLIE
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:MARSH
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 1:115 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1434
Mailing Address - Country:US
Mailing Address - Phone:218-651-0212
Mailing Address - Fax:
Practice Address - Street 1:115 5TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1434
Practice Address - Country:US
Practice Address - Phone:218-651-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8-15-14101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455895Medicaid