Provider Demographics
NPI:1467829168
Name:PPSM
Entity Type:Organization
Organization Name:PPSM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICSW
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:UZENDOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-644-0415
Mailing Address - Street 1:1061 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3002
Mailing Address - Country:US
Mailing Address - Phone:651-212-4920
Mailing Address - Fax:
Practice Address - Street 1:1061 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3002
Practice Address - Country:US
Practice Address - Phone:651-212-4920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty