Basic Information
| Provider Information | |||||||||
| NPI: | 1437772803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | KATHI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ACKERMAN | ||||||||
| OtherFirstName: | KATHI | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3839 FOX TRL | ||||||||
| Address2: | |||||||||
| City: | ST BONIFACIUS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553751214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524842195 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 280 SMITH AVE N STE 450 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512415959 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2020 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 22793 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.