Provider Demographics
NPI:1700919073
Name:VAN DUSEN, KERRY LYNN (PSYD LP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:LYNN
Last Name:VAN DUSEN
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W SUPERIOR ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802
Mailing Address - Country:US
Mailing Address - Phone:218-740-3026
Mailing Address - Fax:218-740-3030
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802
Practice Address - Country:US
Practice Address - Phone:218-740-3026
Practice Address - Fax:218-740-3030
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN174M6N0OtherBCBS
MN174M7VAOtherBCBS
MN705222700Medicaid