Provider Demographics
NPI:1952432130
Name:SERSLAND BRADY, KIMBERLY PAULETTE (MA, LP, LPCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAULETTE
Last Name:SERSLAND BRADY
Suffix:
Gender:F
Credentials:MA, LP, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 SHRYER AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5937
Mailing Address - Country:US
Mailing Address - Phone:612-597-4135
Mailing Address - Fax:
Practice Address - Street 1:4432 CHICAGO AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-870-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5092103T00000X
MNCC00257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional