Provider Demographics
NPI:1477566826
Name:KIESEL, LISA RENEE (LICSW)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:KIESEL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 SELBY AVE # 2
Mailing Address - Street 2:.SUITE 106
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6218
Mailing Address - Country:US
Mailing Address - Phone:612-251-7967
Mailing Address - Fax:
Practice Address - Street 1:1599 SELBY AVE # 2
Practice Address - Street 2:.SUITE 106
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6218
Practice Address - Country:US
Practice Address - Phone:612-251-7967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002196OtherMEDICARE
MN866412900Medicaid