Provider Demographics
NPI:1518140391
Name:ZUCHORA-WALSKE, RON JOSEPH (CLINICALSOCIALWORKER)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:JOSEPH
Last Name:ZUCHORA-WALSKE
Suffix:
Gender:M
Credentials:CLINICALSOCIALWORKER
Other - Prefix:
Other - First Name:RON
Other - Middle Name:JOSEPH
Other - Last Name:ZUCHORA-WALSKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:5733 14TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1001
Mailing Address - Country:US
Mailing Address - Phone:612-719-0965
Mailing Address - Fax:
Practice Address - Street 1:5939 PORTLAND AVE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-689-4444
Practice Address - Fax:612-254-8244
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24636101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN642492100Medicaid
MN24636OtherNEW ADDITIONAL LICENSE #