Provider Demographics
NPI:1558015875
Name:MIKLAS, KELLY JEAN (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:MIKLAS
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 HUDSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4455
Mailing Address - Country:US
Mailing Address - Phone:952-460-9090
Mailing Address - Fax:
Practice Address - Street 1:6063 HUDSON RD STE 200
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4455
Practice Address - Country:US
Practice Address - Phone:952-460-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional