Provider Demographics
NPI:1881006880
Name:KODALEN, KENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:
Last Name:KODALEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CHICAGO AVE
Mailing Address - Street 2:MAIL STOP 17-217
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4518
Mailing Address - Country:US
Mailing Address - Phone:612-813-7042
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:MAIL STOP 17-217
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-24
Last Update Date:2014-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5742103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent