Provider Demographics
NPI:1306420310
Name:MUNSON, KEITH WARREN
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WARREN
Last Name:MUNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 201ST ST W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-9346
Mailing Address - Country:US
Mailing Address - Phone:651-269-8523
Mailing Address - Fax:
Practice Address - Street 1:3450 OLEARY LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2340
Practice Address - Country:US
Practice Address - Phone:651-365-8523
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3565106H00000X
MN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist