Provider Demographics
NPI:1942681879
Name:WESNER, KELLY (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WESNER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LOIDOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:7123 POLARIS LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3224
Mailing Address - Country:US
Mailing Address - Phone:612-309-5527
Mailing Address - Fax:
Practice Address - Street 1:7200 FORESTVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-5571
Practice Address - Country:US
Practice Address - Phone:763-200-1466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical