Provider Demographics
NPI:1437560836
Name:PROKOPANKO, ALLISA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ALLISA
Middle Name:
Last Name:PROKOPANKO
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5253 BEARD AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2117
Mailing Address - Country:US
Mailing Address - Phone:952-607-7632
Mailing Address - Fax:612-728-5301
Practice Address - Street 1:6458 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3245
Practice Address - Country:US
Practice Address - Phone:952-767-6791
Practice Address - Fax:612-728-5301
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN204441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical