Healthcare Provider Details

I. General information

NPI: 1043380074
Provider Name (Legal Business Name): KIRSTEN LYSNE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 HENNEPIN AVE SOUTH #B301
MPLS MN
55408
US

IV. Provider business mailing address

3001 HENNEPIN AVE SO #B301
MPLS MN
55408
US

V. Phone/Fax

Practice location:
  • Phone: 612-825-3440
  • Fax: 612-827-2477
Mailing address:
  • Phone: 612-825-3440
  • Fax: 612-827-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3655
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: