Provider Demographics
NPI:1558007922
Name:MASTERTON, KRISTIN R (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:R
Last Name:MASTERTON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9107 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-8003
Mailing Address - Country:US
Mailing Address - Phone:763-227-7166
Mailing Address - Fax:
Practice Address - Street 1:2100 3RD AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2235
Practice Address - Country:US
Practice Address - Phone:763-227-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN285731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical