Provider Demographics
NPI:1417327347
Name:ONYENEHO, KATE
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:ONYENEHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 BASS LAKE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2766
Mailing Address - Country:US
Mailing Address - Phone:952-356-2953
Mailing Address - Fax:
Practice Address - Street 1:6000 BASS LAKE RD STE 206
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-2766
Practice Address - Country:US
Practice Address - Phone:952-356-2953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN244361041C0700X
MN365664385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1952685158OtherMEDICAID R & B
MN1952685158Medicaid
MN1952685158Medicaid
MN1952685158Medicare Oscar/Certification
MN1952685158Medicare NSC
MN1952685158Medicare PIN