Provider Demographics
NPI:1528707528
Name:HALLINGSTAD, KELLEY ANNE (MA, LADC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:HALLINGSTAD
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 TOWER DR W STE 100
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7609
Mailing Address - Country:US
Mailing Address - Phone:651-390-5001
Mailing Address - Fax:651-390-5002
Practice Address - Street 1:1715 TOWER DR W STE 100
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7609
Practice Address - Country:US
Practice Address - Phone:651-390-5001
Practice Address - Fax:651-390-5002
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)