Healthcare Provider Details

I. General information

NPI: 1518714146
Provider Name (Legal Business Name): KAITLYNN PONTIUS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAITLYNN RIVERS

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6936 PINE ARBOR DR S STE 200
COTTAGE GROVE MN
55016-4672
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW STE 110
NEW BRIGHTON MN
55112-1789
US

V. Phone/Fax

Practice location:
  • Phone: 651-461-2903
  • Fax: 651-461-2904
Mailing address:
  • Phone: 651-461-2903
  • Fax: 651-461-2904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: