Provider Demographics
NPI:1407116155
Name:VENABLES, KRISTIN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:M
Last Name:VENABLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4215
Mailing Address - Country:US
Mailing Address - Phone:763-588-0661
Mailing Address - Fax:763-302-4345
Practice Address - Street 1:4225 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4215
Practice Address - Country:US
Practice Address - Phone:763-588-0661
Practice Address - Fax:763-302-4345
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8956103T00000X
MNLP5885103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPSY003569OtherMEDICAL LICENSE
MNLP5885OtherMEDICAL LICENSE