Provider Demographics
NPI:1578643730
Name:KILDAHL, KRISTIN SKOOG (MA LP)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:SKOOG
Last Name:KILDAHL
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9923 BROOKSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2826
Mailing Address - Country:US
Mailing Address - Phone:612-272-5107
Mailing Address - Fax:952-657-5153
Practice Address - Street 1:9001 E. BLOOMINGTON FREEWAY
Practice Address - Street 2:STE 139D
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-657-5153
Practice Address - Fax:952-657-5156
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1384103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP19178OtherHEALTH PARTNERS
MNBHPOtherBHP
MN228G8K1OtherBCBS
MN6295175OtherMEDICA
MN051250800Medicaid