Healthcare Provider Details

I. General information

NPI: 1699147827
Provider Name (Legal Business Name): KRISTA COSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CLEVELAND AVE S STE 223
SAINT PAUL MN
55116-3867
US

IV. Provider business mailing address

548 SUPERIOR ST APT 2W
SAINT PAUL MN
55102-3253
US

V. Phone/Fax

Practice location:
  • Phone: 317-441-4041
  • Fax:
Mailing address:
  • Phone: 317-441-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4781
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: