Provider Demographics
NPI:1487867230
Name:RIKALA, KELLI LEE (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LEE
Last Name:RIKALA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:LEE
Other - Last Name:MOSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:2016 CARLTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-2133
Mailing Address - Country:US
Mailing Address - Phone:218-879-8532
Mailing Address - Fax:
Practice Address - Street 1:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - Street 2:927 TRETTEL LANE
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-3755
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN170851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNPP000Medicare UPIN