Provider Demographics
NPI:1578037594
Name:SWANSON, KELLY (MA, LPCC, RPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MA, LPCC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2463 180TH AVE
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-7219
Mailing Address - Country:US
Mailing Address - Phone:320-291-7291
Mailing Address - Fax:
Practice Address - Street 1:220 RAILROAD ST SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1540
Practice Address - Country:US
Practice Address - Phone:320-629-7600
Practice Address - Fax:651-925-0071
Is Sole Proprietor?:No
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health