Provider Demographics
NPI:1245589274
Name:KITTLESON, GAYLE L (LMFT)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:L
Last Name:KITTLESON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR TOWNSHIP
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5741
Mailing Address - Country:US
Mailing Address - Phone:651-762-0998
Mailing Address - Fax:
Practice Address - Street 1:1385 MENDOTA HEIGHTS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1368
Practice Address - Country:US
Practice Address - Phone:651-379-9800
Practice Address - Fax:651-405-0358
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1408106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist