Provider Demographics
NPI:1225211212
Name:STRUB, KATY L (LICSW)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:L
Last Name:STRUB
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 1:101 W BURNSVILLE PKWY STE 207
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-0010
Mailing Address - Country:US
Mailing Address - Phone:612-405-2261
Mailing Address - Fax:952-686-6966
Practice Address - Street 1:1500 MCANDREWS RD W STE 215
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4445
Practice Address - Country:US
Practice Address - Phone:612-405-2261
Practice Address - Fax:612-437-4587
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18840104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN782963300Medicaid