Provider Demographics
NPI:1336245455
Name:MARY BETH KIBORT, LLC
Entity Type:Organization
Organization Name:MARY BETH KIBORT, LLC
Other - Org Name:MARY BETH KIBORT, PSY.D., LP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBORT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:651-645-2890
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:651-645-2890
Mailing Address - Fax:651-645-4603
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-645-2890
Practice Address - Fax:651-645-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103255OtherHEALTHPARTNERS
MN330LOKIOtherBCBS
MN6157722OtherMEDICA/UBH
MN122502OtherUCARE