Healthcare Provider Details

I. General information

NPI: 1356870778
Provider Name (Legal Business Name): KATHLEEN LOUISE KOCON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 COMO AVE.
SAINT PAUL MN
55108
US

IV. Provider business mailing address

2230 COMO AVE
SAINT PAUL MN
55108-1720
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3401
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: