Provider Demographics
NPI:1437772803
Name:ACKERMAN, KATHI MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:MARIE
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KATHI
Other - Middle Name:MARIE
Other - Last Name:ACKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3839 FOX TRL
Mailing Address - Street 2:
Mailing Address - City:ST BONIFACIUS
Mailing Address - State:MN
Mailing Address - Zip Code:55375-1214
Mailing Address - Country:US
Mailing Address - Phone:952-484-2195
Mailing Address - Fax:
Practice Address - Street 1:280 SMITH AVE N STE 450
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2481
Practice Address - Country:US
Practice Address - Phone:651-241-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN227931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical