Provider Demographics
NPI:1457790990
Name:MOEN, KRISTIN LEE (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LEE
Last Name:MOEN
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEE
Other - Last Name:IRWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPCC
Mailing Address - Street 1:12425 RIVER RIDGE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4872
Mailing Address - Country:US
Mailing Address - Phone:952-562-8500
Mailing Address - Fax:952-562-8801
Practice Address - Street 1:13000 63RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6081
Practice Address - Country:US
Practice Address - Phone:763-553-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health