Basic Information
| Provider Information | |||||||||
| NPI: | 1205092277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POITRA | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7066 STILLWATER BLVD N | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551283937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517775222 | ||||||||
| FaxNumber: | 6512515111 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 ORLEANS ST E | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550825830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514302720 | ||||||||
| FaxNumber: | 6513513155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 16993 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.