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501 4th St S Ste 201 Princeton MN 55371-4754 | |
| (763) 498-1822 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 501 4th St S Ste 201, Princeton, Minnesota |
| Authorized Official Name and Position | Jacqueline Kelly-faddler (OWNER) |
| Authorized Official Contact | 7634981822 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
501 4th St S Ste 201 Princeton MN 55371-4754 Ph: (763) 498-1822 | 501 4th St S Ste 201 Princeton MN 55371-4754 Ph: (763) 498-1822 |
| NPI Number | 1497246433 |
|---|---|
| Provider Enumeration Date | 05/25/2018 |
| Last Update Date | 06/14/2024 |
| Certification Date | 06/14/2024 |
| Medicare PECOS PAC ID | 2567906183 |
|---|---|
| Medicare Enrollment ID | O20240706000195 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1497246433 | NPI | - | NPPES |
| 1497246433 | Medicaid | MN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | 00842 (Minnesota) | Primary |
| Provider Name | Jacqueline Kelly-faddler |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1881020527 PECOS PAC ID: 3476097098 Enrollment ID: I20240706000216 |
| Provider Name | Tanya Anne Lambert |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1679929640 PECOS PAC ID: 3072058916 Enrollment ID: I20240715004011 |
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