Provider Demographics
NPI:1508359704
Name:DIESCH-CHHAM, ATHENA MARIE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ATHENA
Middle Name:MARIE
Last Name:DIESCH-CHHAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22426 CANTREL WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-4011
Mailing Address - Country:US
Mailing Address - Phone:507-676-1633
Mailing Address - Fax:
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:507-676-1633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN209551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical