Provider Demographics
NPI:1154422012
Name:AVENSON, KIMBERLY JEAN SLETTA (MSW, LICSW)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JEAN SLETTA
Last Name:AVENSON
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:722 15TH STREET N.W.
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56619-0640
Practice Address - Country:US
Practice Address - Phone:218-751-3280
Practice Address - Fax:218-751-3298
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN154001041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN153485800Medicaid
MN800001617Medicare ID - Type Unspecified