Provider Demographics
NPI:1437627353
Name:ACKERMAN, KELLY ELAINE (CMT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELAINE
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 COOPER AVE N STE 160
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4418
Mailing Address - Country:US
Mailing Address - Phone:320-309-7284
Mailing Address - Fax:
Practice Address - Street 1:203 COOPER AVE N STE 160
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4418
Practice Address - Country:US
Practice Address - Phone:320-309-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20-1889495Medicaid