Provider Demographics
NPI:1295116044
Name:KINZER, KATHRYN M
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:KINZER
Suffix:
Gender:F
Credentials:
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 ROAD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-379-1718
Mailing Address - Fax:651-379-1738
Practice Address - Street 1:3701 12TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-3512
Practice Address - Fax:320-253-1037
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional