Provider Demographics
NPI:1750308425
Name:KADLEC, KELLY E (EDD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:KADLEC
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1802
Mailing Address - Country:US
Mailing Address - Phone:701-234-4111
Mailing Address - Fax:701-234-4130
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-4111
Practice Address - Fax:701-234-4130
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND349103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN266913700Medicaid
ND11724Medicaid
MN266913700Medicaid
ND11724Medicaid