Provider Demographics
NPI:1811230162
Name:DE LEON BRAN, KELLY (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DE LEON BRAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3461
Mailing Address - Country:US
Mailing Address - Phone:612-871-1454
Mailing Address - Fax:612-871-1505
Practice Address - Street 1:2430 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3461
Practice Address - Country:US
Practice Address - Phone:612-871-1454
Practice Address - Fax:612-871-1505
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN178851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical