Basic Information
| Provider Information | |||||||||
| NPI: | 1447395629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEY | ||||||||
| FirstName: | MARY LOU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4068 40TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565607504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014515057 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581032311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014514900 | ||||||||
| FaxNumber: | 7014515057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2841 | ND | Y | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | 11721 | MN | N | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 067H4BR | 01 | MN | BCBSMN | OTHER | 62-67227 | 01 | ND | MEDICA UBH | OTHER | HP59873 | 01 | ND | HEALTH PARTNERS | OTHER | 26563 | 01 | ND | BCBSND | OTHER | 19162 | 05 | ND | MEDICAID | 158498700 | 05 | MN | MEDICAID | 58103-A009 | 01 | ND | TRIWEST | OTHER |