Provider Demographics
NPI:1912217480
Name:SUMMERS, KELLY (LADC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 COUNTY HIGHWAY 10
Mailing Address - Street 2:108
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1253
Mailing Address - Country:US
Mailing Address - Phone:763-355-5092
Mailing Address - Fax:
Practice Address - Street 1:950 COUNTY HIGHWAY 10
Practice Address - Street 2:108
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-1253
Practice Address - Country:US
Practice Address - Phone:763-355-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302446101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)