Provider Demographics
NPI:1043651052
Name:CROSSROADS COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:CROSSROADS COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KITTILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LICSW, LADC
Authorized Official - Phone:651-276-8446
Mailing Address - Street 1:6053 HUDSON RD STE 192
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1015
Mailing Address - Country:US
Mailing Address - Phone:651-276-8446
Mailing Address - Fax:
Practice Address - Street 1:6053 HUDSON RD STE 192
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1015
Practice Address - Country:US
Practice Address - Phone:651-276-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301518101YA0400X
MN130331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty