Provider Demographics
NPI:1134477268
Name:ARMENDARIZ, KATY KIM (LICSW)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:KIM
Last Name:ARMENDARIZ
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 1:5724 36TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2908
Mailing Address - Country:US
Mailing Address - Phone:612-710-2797
Mailing Address - Fax:
Practice Address - Street 1:3405 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2107
Practice Address - Country:US
Practice Address - Phone:612-710-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN198371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800003275OtherMEDICARE INDIVIDUAL PTAN