Provider Demographics
NPI:1508575069
Name:PEDERSON, KELSI
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:PEDERSON
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 1:929 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-2518
Mailing Address - Country:US
Mailing Address - Phone:701-739-3554
Mailing Address - Fax:
Practice Address - Street 1:1530 1ST AVE N STE 150
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-0002
Practice Address - Country:US
Practice Address - Phone:218-228-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician