Healthcare Provider Details

I. General information

NPI: 1720614001
Provider Name (Legal Business Name): WILLIAM KIRKLAND I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date: 05/20/2024
Reactivation Date: 06/14/2024

III. Provider practice location address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

IV. Provider business mailing address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

V. Phone/Fax

Practice location:
  • Phone: 651-280-2310
  • Fax: 651-280-3995
Mailing address:
  • Phone: 651-280-2310
  • Fax: 651-280-3995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4294
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: