Provider Demographics
NPI:1437930682
Name:STEPHAN, KIM E (LADC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:E
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 3RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1443
Mailing Address - Country:US
Mailing Address - Phone:320-629-0059
Mailing Address - Fax:320-629-9983
Practice Address - Street 1:509 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1508
Practice Address - Country:US
Practice Address - Phone:651-491-6508
Practice Address - Fax:320-629-9983
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305303101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)