Provider Demographics
NPI:1285903229
Name:MALEY, KIMBERLY HAYES (LADC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HAYES
Last Name:MALEY
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 1:1909 SOUTHCROSS DR W APT 1607
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7955
Mailing Address - Country:US
Mailing Address - Phone:612-840-7289
Mailing Address - Fax:
Practice Address - Street 1:400 SIBLEY ST STE 500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1938
Practice Address - Country:US
Practice Address - Phone:651-256-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303232101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)