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General NPI Number Information
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NPI Number | 1063244952
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Entity Type | Individual
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Provider Name | KILLY KITZMANN LADC, LPC-IT
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Gender | Male
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Dates
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Enumeration Date | 08/19/2024
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Last Update Date | 01/14/2026
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Provider Practice Location Address
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Address Line | 6640 SHADY OAK RD STE 401
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-7834
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Country | US
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Telephone | 715-256-7166
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Fax | 888-427-8048
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Provider Business Mailing Address
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Address Line | 800 WILSON AVE RM 330
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City | MENOMONIE
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State | WI
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Zip | 54751-2746
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Country | US
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Telephone | 715-256-7166
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Fax | 888-427-8048
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 307059
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 8849-226
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License Number State | WI
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