Provider Demographics
NPI:1174788947
Name:KITTELSON, MARY LYNN (LP, JUNGIAN ANALYST)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:KITTELSON
Suffix:
Gender:F
Credentials:LP, JUNGIAN ANALYST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 PRIOR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5406
Mailing Address - Country:US
Mailing Address - Phone:651-489-7484
Mailing Address - Fax:
Practice Address - Street 1:1711 COUNTY ROAD B W
Practice Address - Street 2:SUITE 205-S
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4057
Practice Address - Country:US
Practice Address - Phone:651-276-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ102L00000X
MN2078103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP911100OtherNATIONAL ASSOCIATION FOR THE ADVANCEMENT OF PSYCHOANALYSIS
MN1409168OtherMN STATE TAX ID