MEDICARE: KATELYN MARIE CHRISTENSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	305353	MN

General Provider Information

NPI Number	:	1689232035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN MARIE CHRISTENSEN

Provider Business Mailing Address
First Line	:	4029 UTICA AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2904
Country	:	US
Telephone Number	:	952-928-9390
Fax Number	:	952-836-2410

Provider Business Practice Location Address
First Line	:	4029 UTICA AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2904
Country	:	US
Telephone Number	:	952-928-9390
Fax Number	:	952-836-2410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2019
Last Update Date	:	05/31/2019

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