Provider Demographics
NPI:1598194201
Name:BURGESS, KRISTY LEE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-379-1718
Mailing Address - Fax:651-379-1738
Practice Address - Street 1:1811 WEIR DRIVE
Practice Address - Street 2:SUITE 270
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-714-9646
Practice Address - Fax:651-714-9647
Is Sole Proprietor?:No
Enumeration Date:2013-11-03
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000427106H00000X
MN2413106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist