Healthcare Provider Details

I. General information

NPI: 1881114056
Provider Name (Legal Business Name): KAITLIN LEZCANO LYTLE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 MONTEREY DR
ST LOUIS PARK MN
55416-5275
US

IV. Provider business mailing address

4620 YORK AVE S
MINNEAPOLIS MN
55410-1866
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5990
  • Fax:
Mailing address:
  • Phone: 612-308-0246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: