Healthcare Provider Details

I. General information

NPI: 1073399291
Provider Name (Legal Business Name): CODY JAMES KIRK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13911 RIDGEDALE DR STE 490
MINNETONKA MN
55305-1772
US

IV. Provider business mailing address

77 COMMERCIAL ST APT 531
BROOKLYN NY
11222-8043
US

V. Phone/Fax

Practice location:
  • Phone: 612-293-5823
  • Fax:
Mailing address:
  • Phone: 952-356-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number05350
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: