Provider Demographics
NPI:1871103432
Name:STICKLEY, KRISTYN SANDRA
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:SANDRA
Last Name:STICKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1456 LAGOON AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1950
Mailing Address - Country:US
Mailing Address - Phone:484-612-2426
Mailing Address - Fax:
Practice Address - Street 1:3801 W 50TH ST STE 250B
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-2070
Practice Address - Country:US
Practice Address - Phone:612-400-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor