Provider Demographics
NPI:1508405879
Name:KURKOSKY, MALLORY (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KURKOSKY
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18247 KERRVILLE TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-7296
Mailing Address - Country:US
Mailing Address - Phone:507-351-4501
Mailing Address - Fax:
Practice Address - Street 1:7580 160TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8348
Practice Address - Country:US
Practice Address - Phone:952-898-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional