Provider Demographics
NPI:1851706535
Name:WICKLUND, KRIS CARL I (LMFT, LADC)
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:CARL
Last Name:WICKLUND
Suffix:I
Gender:M
Credentials:LMFT, LADC
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
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-379-1718
Mailing Address - Fax:651-379-1738
Practice Address - Street 1:11010 PRAIRIE LAKES DR
Practice Address - Street 2:SUITE 350
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3884
Practice Address - Country:US
Practice Address - Phone:952-746-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-21
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303844101YA0400X
MN2896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)