Provider Demographics
NPI:1962401380
Name:WELLSTONE, LEAH (MA LMFT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:WELLSTONE
Suffix:
Gender:F
Credentials:MA LMFT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:KIEWEIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8640 EAGLE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-4400
Mailing Address - Country:US
Mailing Address - Phone:952-994-6896
Mailing Address - Fax:
Practice Address - Street 1:8640 EAGLE CREEK CIR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-4400
Practice Address - Country:US
Practice Address - Phone:952-994-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1187106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN699473300Medicaid