Provider Demographics
NPI:1649348095
Name:SWINSON-STAFFORD, KIMBERLY KAY (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:SWINSON-STAFFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KAY
Other - Last Name:DE KAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 COMMERCE DR.
Mailing Address - Street 2:SUITE 290
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-714-3848
Mailing Address - Fax:651-344-0820
Practice Address - Street 1:700 COMMERCE DR.
Practice Address - Street 2:SUITE 290
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-714-3848
Practice Address - Fax:651-344-0820
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1379106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN342129500Medicare ID - Type UnspecifiedMEDICAL ASSISTANCE