Provider Demographics
NPI:1275699381
Name:KUUSISTO-LATHROP, AMY PATRICE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:PATRICE
Last Name:KUUSISTO-LATHROP
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:KUUSISTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 350
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2155
Practice Address - Country:US
Practice Address - Phone:763-503-8560
Practice Address - Fax:763-503-8563
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29155880Medicaid