Provider Demographics
NPI:1588189955
Name:CARLSON GIBAS, KELLY JOAN (DBH)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JOAN
Last Name:CARLSON GIBAS
Suffix:
Gender:F
Credentials:DBH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9060 203RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-8052
Mailing Address - Country:US
Mailing Address - Phone:763-913-4387
Mailing Address - Fax:763-424-2711
Practice Address - Street 1:13700 REIMER DR N STE 220
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-4548
Practice Address - Country:US
Practice Address - Phone:763-424-2474
Practice Address - Fax:763-424-2711
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN133NN1002X, 174H00000X
MNCC01539103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator