Provider Demographics
NPI:1467277723
Name:SHOWALTER, KELLY MARIE (MA, LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:SHOWALTER
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2497 7TH AVE E STE 108
Mailing Address - Street 2:
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2949
Mailing Address - Country:US
Mailing Address - Phone:651-769-6437
Mailing Address - Fax:651-769-6599
Practice Address - Street 1:8441 WAYZATA BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1366
Practice Address - Country:US
Practice Address - Phone:651-769-6300
Practice Address - Fax:651-759-6349
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional