Provider Demographics
NPI:1063930691
Name:DORGAN, KRISTA JO (MA, LMFT)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:JO
Last Name:DORGAN
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4723 PARSONS COURT SOUTH
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:MN
Mailing Address - Zip Code:55001
Mailing Address - Country:US
Mailing Address - Phone:612-501-4228
Mailing Address - Fax:
Practice Address - Street 1:2217 VINE STREET #206
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:55001
Practice Address - Country:US
Practice Address - Phone:651-998-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2809106H00000X
WI1155-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist