MEDICARE: KATHERINE JANE FLYNN LPC, LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	300107	MN
2	101YP2500X	Professional Counselor	00065	MN

General Provider Information

NPI Number	:	1700958295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE JANE FLYNN LPC, LADC

Provider Business Mailing Address
First Line	:	5009 EXCELSIOR BLVD STE 134
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-3049
Country	:	US
Telephone Number	:	612-819-5326
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 EXCELSIOR BLVD STE 134
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-3049
Country	:	US
Telephone Number	:	612-819-5326
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	05/30/2012

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