Provider Demographics
NPI:1134283534
Name:KOTANSKY, CORIE SHARON (LICSW)
Entity Type:Individual
Prefix:MS
First Name:CORIE
Middle Name:SHARON
Last Name:KOTANSKY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 5TH ST SE STE 208D
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-4502
Mailing Address - Country:US
Mailing Address - Phone:612-721-3318
Mailing Address - Fax:612-379-2511
Practice Address - Street 1:1313 5TH ST SE STE 208D
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4502
Practice Address - Country:US
Practice Address - Phone:612-721-3318
Practice Address - Fax:612-379-2511
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62 62359OtherUBH MEDICA
MN063L9KOOtherBLUE CROSS BLUE SHIELD
MN01025895OtherPREFERRED ONE