Provider Demographics
NPI:1376903187
Name:CAO, DIEM THI KIM HONG (LICSW, LADC)
Entity Type:Individual
Prefix:
First Name:DIEM
Middle Name:THI KIM HONG
Last Name:CAO
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 OLEARY LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2340
Mailing Address - Country:US
Mailing Address - Phone:651-454-0114
Mailing Address - Fax:651-454-3492
Practice Address - Street 1:2785 WHITE BEAR AVE N
Practice Address - Street 2:SUIT 403
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1307
Practice Address - Country:US
Practice Address - Phone:651-454-0114
Practice Address - Fax:651-454-3492
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304113101YA0400X
MN219381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)