Provider Demographics
NPI:1851458582
Name:RICKORD, KATIE LYN (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:LYN
Last Name:RICKORD
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 1:700 COMMERCE DR STE 290
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9256
Mailing Address - Country:US
Mailing Address - Phone:612-619-0086
Mailing Address - Fax:651-344-0820
Practice Address - Street 1:8421 WAYZATA BLVD STE 305
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1395
Practice Address - Country:US
Practice Address - Phone:612-619-0086
Practice Address - Fax:651-344-0820
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 5109103T00000X
MNLPC #00301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP59141OtherHEALTHPARTNERS