1396197117 NPI number — MRS. KYSA LORENC LUBOVICH LMFT

Table of content: MRS. KYSA LORENC LUBOVICH LMFT (NPI 1396197117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396197117 NPI number — MRS. KYSA LORENC LUBOVICH LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUBOVICH
Provider First Name:
KYSA
Provider Middle Name:
LORENC
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
KYSA
Provider Other Middle Name:
LORENTZ
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396197117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7066 STILLWATER BLVD N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55128-3937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-401-3062
Provider Business Mailing Address Fax Number:
651-674-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 COUNTY ROAD B2 W STE 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113-2788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-388-5897
Provider Business Practice Location Address Fax Number:
651-340-3237
Provider Enumeration Date:
07/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  3159 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com