Provider Demographics
NPI:1760854061
Name:KINNEY, ELIZABETH R (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:KINNEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:RYPSTAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:218-364-8000
Mailing Address - Fax:
Practice Address - Street 1:530 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1913
Practice Address - Country:US
Practice Address - Phone:218-786-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18943104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker