Provider Demographics
NPI:1952364416
Name:KLEIN, KENNETH M (PHD LP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:KLEIN
Suffix:
Gender:M
Credentials:PHD LP
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:2345 ARIEL STREET NORTH
Practice Address - Street 2:MAIL STOP 13601A
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2248
Practice Address - Country:US
Practice Address - Phone:651-254-4793
Practice Address - Fax:651-254-0877
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R68665Medicare UPIN