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General NPI Number Information
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NPI Number | 1962040469
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Entity Type | Individual
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Provider Name | KRISTIN SOUTHWORTH
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Gender | Female
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Dates
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Enumeration Date | 12/16/2019
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Last Update Date | 01/06/2023
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Provider Practice Location Address
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Address Line | 18205 45TH AVE N STE C
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City | PLYMOUTH
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State | MN
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Zip | 55446-4594
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Country | US
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Telephone | 651-478-4099
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Fax |
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Provider Business Mailing Address
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Address Line | 868 CARROLL AVE
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City | SAINT PAUL
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State | MN
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Zip | 55104-5411
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Country | US
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Telephone |
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 2296
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License Number State | MN
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