Healthcare Provider Details

I. General information

NPI: 1710118054
Provider Name (Legal Business Name): KATHRYN ANNE WYMAN-CHICK PSY.D, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. KATHRYN ANNE WYMAN

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 PHALEN BLVD
SAINT PAUL MN
55130-2400
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-495-6200
  • Fax:
Mailing address:
  • Phone: 651-254-7900
  • Fax: 651-254-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6151
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005336
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP6151
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: