Healthcare Provider Details

I. General information

NPI: 1174788947
Provider Name (Legal Business Name): MARY LYNN KITTELSON LP, JUNGIAN ANALYST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 COUNTY ROAD B W SUITE 205-S
ROSEVILLE MN
55113-4057
US

IV. Provider business mailing address

1975 PRIOR AVE N
SAINT PAUL MN
55113-5406
US

V. Phone/Fax

Practice location:
  • Phone: 651-276-0305
  • Fax:
Mailing address:
  • Phone: 651-489-7484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2078
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: