Provider Demographics
NPI:1205955978
Name:EDENS, KIMBERLEY MARIE (LADC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:MARIE
Last Name:EDENS
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 1:763 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54015-9781
Mailing Address - Country:US
Mailing Address - Phone:651-270-2123
Mailing Address - Fax:
Practice Address - Street 1:1121 JACKSON ST NE
Practice Address - Street 2:SUITE 105
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1672
Practice Address - Country:US
Practice Address - Phone:612-236-1705
Practice Address - Fax:612-236-1701
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301386101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)