Provider Demographics
NPI:1376151977
Name:KWST TARGETED BEHAVIORAL DEVELOPMENT GROUP
Entity Type:Organization
Organization Name:KWST TARGETED BEHAVIORAL DEVELOPMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEARY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:SAFFOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:612-518-6009
Mailing Address - Street 1:333 WASHINGTON AVE N STE 323
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1366
Mailing Address - Country:US
Mailing Address - Phone:612-518-6009
Mailing Address - Fax:
Practice Address - Street 1:333 WASHINGTON AVE N STE 323
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1366
Practice Address - Country:US
Practice Address - Phone:612-518-6009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Single Specialty