Provider Demographics
NPI:1669796058
Name:KRISTIN S. KILDAHL, MA, LP, LLC
Entity type:Organization
Organization Name:KRISTIN S. KILDAHL, MA, LP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:SKOOG
Authorized Official - Last Name:KILDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:612-272-5107
Mailing Address - Street 1:9923 BROOKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2826
Mailing Address - Country:US
Mailing Address - Phone:612-272-5107
Mailing Address - Fax:651-730-6657
Practice Address - Street 1:7200 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4300
Practice Address - Country:US
Practice Address - Phone:612-272-5107
Practice Address - Fax:651-730-6657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1578643730OtherTYPE 1 NPI #
MN1578643730Medicaid