MEDICARE: KIRBY KACZOR LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	4263	MN

General Provider Information

NPI Number	:	1003679234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRBY KACZOR LPCC

Provider Business Mailing Address
First Line	:	2025 4TH ST STE 100
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-2875
Country	:	US
Telephone Number	:	651-212-4920
Fax Number	:

Provider Business Practice Location Address
First Line	:	2025 4TH ST STE 100
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-2875
Country	:	US
Telephone Number	:	651-212-4920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2024
Last Update Date	:	01/31/2024

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