Provider Demographics
NPI:1104152032
Name:LANDIS, KELSEY ANN (LMFT)
Entity type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:ANN
Last Name:LANDIS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 33RD AVE N STE 103
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1929
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:325 33RD AVE N STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1929
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:320-252-2567
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1742106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN273940100Medicaid