Provider Demographics
NPI:1689308512
Name:SALAYA-MOLINA, KEVIN WALDEMAR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WALDEMAR
Last Name:SALAYA-MOLINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 STINSON BLVD NE STE 314
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-3424
Mailing Address - Country:US
Mailing Address - Phone:612-298-7636
Mailing Address - Fax:612-354-3801
Practice Address - Street 1:1410 CIRCLE TERRACE BLVD NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-3148
Practice Address - Country:US
Practice Address - Phone:763-321-0457
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician