Basic Information
Provider Information | |||||||||
NPI: | 1710118054 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYMAN-CHICK | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D, LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WYMAN | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8170 33RD AVE S | ||||||||
Address2: | MS 21110Q | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554254516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512547900 | ||||||||
FaxNumber: | 6512547904 | ||||||||
Practice Location | |||||||||
Address1: | 640 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551012502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512547900 | ||||||||
FaxNumber: | 6512547904 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2009 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0810005336 | VA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | LP6151 | MN | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 103G00000X | LP6151 | MN | Y |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.