Provider Demographics
NPI:1386113876
Name:PELTOLA, KYLE LOUIS (MED, LPCC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:LOUIS
Last Name:PELTOLA
Suffix:
Gender:M
Credentials:MED, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 MCBOAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2723
Mailing Address - Country:US
Mailing Address - Phone:507-626-0500
Mailing Address - Fax:
Practice Address - Street 1:402 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4400
Practice Address - Country:US
Practice Address - Phone:651-587-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health