Healthcare Provider Details

I. General information

NPI: 1801297577
Provider Name (Legal Business Name): DOREEN KUDRLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 HAZELTINE BLVD STE 121
CHASKA MN
55318-1065
US

IV. Provider business mailing address

8401 WAYZATA BLVD STE 150
GOLDEN VALLEY MN
55426-1377
US

V. Phone/Fax

Practice location:
  • Phone: 952-361-3360
  • Fax: 952-513-7968
Mailing address:
  • Phone: 952-361-3360
  • Fax: 952-513-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1120
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: