Healthcare Provider Details

I. General information

NPI: 1003725714
Provider Name (Legal Business Name): TAYLOR KORYNTA LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 229N
SAINT PAUL MN
55114-1902
US

IV. Provider business mailing address

1862 IVAN WAY
SAINT PAUL MN
55116-3222
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-3115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29090
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: