Provider Demographics
NPI:1063863991
Name:STERNHAGEN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STERNHAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 METRO BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3062
Mailing Address - Country:US
Mailing Address - Phone:612-517-3667
Mailing Address - Fax:
Practice Address - Street 1:7401 METRO BLVD STE 250
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-3062
Practice Address - Country:US
Practice Address - Phone:612-517-3667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN206791041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical