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NPI Code Detail

MEDICARE: MARY KELLY KIRK-WILLENBRING MA, LPCC

MEDICARE: MARY KELLY KIRK-WILLENBRING MA, 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
1101YP2500XProfessional CounselorCC03021MN

General Provider Information

NPI Number : 1649939695
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY KELLY KIRK-WILLENBRING MA, LPCC
Provider Business Mailing Address
First Line : 1915 JULIET AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55105-1710
Country : US
Telephone Number : 612-860-7566
Fax Number :
Provider Business Practice Location Address
First Line : 1915 LYNDALE AVE S
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55403-3104
Country : US
Telephone Number : 800-336-5973
Fax Number : 612-234-4689
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/16/2021
Last Update Date : 09/29/2025

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