Provider Demographics
NPI:1255875829
Name:WICKLUND, KJIRSTYN LEE (MA, LPC)
Entity type:Individual
Prefix:
First Name:KJIRSTYN
Middle Name:LEE
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:KJRISTYN
Other - Middle Name:
Other - Last Name:BIRKHOLZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:44 GOOD COUNSEL DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6599
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01933101YP2500X
MN2014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional