Provider Demographics
NPI:1124181656
Name:WICAL, KURT AUSTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:AUSTIN
Last Name:WICAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3499 LEXINGTON AVE N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55126-7055
Mailing Address - Country:US
Mailing Address - Phone:651-486-4828
Mailing Address - Fax:651-482-9119
Practice Address - Street 1:3499 LEXINGTON AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55126-7055
Practice Address - Country:US
Practice Address - Phone:651-486-4828
Practice Address - Fax:651-482-9119
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1357106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN525K5WIOtherBCBS PERSONAL ID
MN6190551OtherUBH PIN
MN523K5WIOtherBCBS GROUP ID
MNHP53169OtherHEALTHPARTNERS PIN