MEDICARE: KATHLEEN M PFAFFINGER PHD LP

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	103TC0700X	Clinical Psychologist	3258	MN

General Provider Information

NPI Number	:	1104898642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN M PFAFFINGER PHD LP

Provider Business Mailing Address
First Line	:	528 MARSHALL AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-1721
Country	:	US
Telephone Number	:	651-221-1963
Fax Number	:	651-221-9070

Provider Business Practice Location Address
First Line	:	570 ASBURY ST
Second Line	:	SUITE 103
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-1849
Country	:	US
Telephone Number	:	651-646-1777
Fax Number	:	651-646-1774

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	07/08/2007

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