Provider Demographics
NPI:1114431376
Name:WEISE, KATHRYN M (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:WEISE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 435S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1907
Mailing Address - Country:US
Mailing Address - Phone:651-286-8527
Mailing Address - Fax:651-647-1861
Practice Address - Street 1:14300 NICOLLET CT STE 130
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-3422
Practice Address - Country:US
Practice Address - Phone:952-435-8814
Practice Address - Fax:952-435-7705
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3044106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist