Provider Demographics
NPI:1447395629
Name:KLEY, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:KLEY
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 1:4068 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7504
Mailing Address - Country:US
Mailing Address - Phone:701-451-4900
Mailing Address - Fax:701-451-5057
Practice Address - Street 1:1201 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2311
Practice Address - Country:US
Practice Address - Phone:701-451-4900
Practice Address - Fax:701-451-5057
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2841101Y00000X
MN11721101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN067H4BROtherBCBSMN
ND62-67227OtherMEDICA UBH
NDHP59873OtherHEALTH PARTNERS
ND26563OtherBCBSND
ND19162Medicaid
MN158498700Medicaid
ND58103-A009OtherTRIWEST