Provider Demographics
NPI:1922497965
Name:K.I.D.S.&FAMILY THERAPY,LLC
Entity Type:Organization
Organization Name:K.I.D.S.&FAMILY THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:K
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-323-8050
Mailing Address - Street 1:11157 ZEALAND AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3595
Mailing Address - Country:US
Mailing Address - Phone:763-710-9949
Mailing Address - Fax:
Practice Address - Street 1:11157 ZEALAND AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3595
Practice Address - Country:US
Practice Address - Phone:763-710-9949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty