Provider Demographics
NPI:1932759842
Name:MCKITTRICK, KEVIN JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:MCKITTRICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FAIRVIEW AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1306
Mailing Address - Country:US
Mailing Address - Phone:781-420-6815
Mailing Address - Fax:
Practice Address - Street 1:2720 FAIRVIEW AVE N STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1306
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY.60967347103T00000X
WAPY60967347103TC2200X
PY-60967347103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent