Provider Demographics
NPI:1013920545
Name:BRANSTAD, KATHLEEN MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BRANSTAD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:BRANSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:22850 PEARL CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7058
Mailing Address - Country:US
Mailing Address - Phone:218-846-3430
Mailing Address - Fax:
Practice Address - Street 1:22850 PEARL CIR
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-7058
Practice Address - Country:US
Practice Address - Phone:218-846-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist