Healthcare Provider Details

I. General information

NPI: 1548245186
Provider Name (Legal Business Name): LAURIE D KOLTES MA, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 DUNLAP ST N
SAINT PAUL MN
55104-4201
US

IV. Provider business mailing address

409 DUNLAP ST N
SAINT PAUL MN
55104-4201
US

V. Phone/Fax

Practice location:
  • Phone: 651-290-9200
  • Fax: 651-290-9210
Mailing address:
  • Phone: 651-290-9200
  • Fax: 651-290-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number4930
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: