Provider Demographics
NPI:1285730424
Name:KIBORT, MARY BETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:KIBORT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 RAYMOND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1503
Mailing Address - Country:US
Mailing Address - Phone:651-645-8300
Mailing Address - Fax:651-645-4603
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-645-8300
Practice Address - Fax:651-645-4603
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122502OtherUCARE
MN6157722OtherMEDICA/UBH
MN103255OtherHEALTHPARTNERS
MN330L0KIOtherBCBS