Healthcare Provider Details

I. General information

NPI: 1700958295
Provider Name (Legal Business Name): KATHERINE JANE FLYNN LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 EXCELSIOR BLVD STE 134
ST LOUIS PARK MN
55416-3049
US

IV. Provider business mailing address

5009 EXCELSIOR BLVD STE 134
ST LOUIS PARK MN
55416-3049
US

V. Phone/Fax

Practice location:
  • Phone: 612-819-5326
  • Fax:
Mailing address:
  • Phone: 612-819-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number300107
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number00065
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: