Provider Demographics
NPI:1528572021
Name:KELSEY LANDIS, MS LMFT LLC
Entity Type:Organization
Organization Name:KELSEY LANDIS, MS LMFT LLC
Other - Org Name:NORTHWEST COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS LMFT
Authorized Official - Phone:320-492-1414
Mailing Address - Street 1:2351 CONNECTICUT AVE S STE 105
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2479
Mailing Address - Country:US
Mailing Address - Phone:320-316-0288
Mailing Address - Fax:
Practice Address - Street 1:2351 CONNECTICUT AVE S STE 105
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2479
Practice Address - Country:US
Practice Address - Phone:320-316-0288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1742261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN273940100Medicaid