Provider Demographics
NPI:1194297390
Name:DANSBERRY, KATHY CLARK (LADC)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:CLARK
Last Name:DANSBERRY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 RHODE ISLAND AVE N APT 324
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4942
Mailing Address - Country:US
Mailing Address - Phone:763-710-7207
Mailing Address - Fax:
Practice Address - Street 1:2738 WINNETKA AVE N # 150M2
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-2850
Practice Address - Country:US
Practice Address - Phone:763-762-8728
Practice Address - Fax:763-762-8762
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300889101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)