Provider Demographics
NPI:1730565144
Name:NOWAK, KELLI (MA, LPCC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:NOWAK
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MN
Mailing Address - Zip Code:55334-0393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334-2386
Practice Address - Country:US
Practice Address - Phone:507-237-9989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01649101YP2500X
IL180.009052101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional