Provider Demographics
NPI:1396197117
Name:LUBOVICH, KYSA LORENC (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KYSA
Middle Name:LORENC
Last Name:LUBOVICH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KYSA
Other - Middle Name:LORENTZ
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-401-3062
Mailing Address - Fax:651-674-2534
Practice Address - Street 1:1935 COUNTY ROAD B2 W STE 41
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2788
Practice Address - Country:US
Practice Address - Phone:612-388-5897
Practice Address - Fax:651-340-3237
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist