Provider Demographics
NPI:1003656760
Name:ILLIG, KURT ROBERT (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:ROBERT
Last Name:ILLIG
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3795 PILOT KNOB RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3176
Mailing Address - Country:US
Mailing Address - Phone:952-595-5652
Mailing Address - Fax:
Practice Address - Street 1:3795 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3176
Practice Address - Country:US
Practice Address - Phone:952-595-5652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP7058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical