Provider Demographics
NPI:1003679234
Name:KACZOR, KIRBY (LPCC)
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:
Last Name:KACZOR
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 4TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2875
Mailing Address - Country:US
Mailing Address - Phone:651-212-4920
Mailing Address - Fax:
Practice Address - Street 1:2025 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2875
Practice Address - Country:US
Practice Address - Phone:651-212-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4263101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor