Provider Demographics
NPI:1568489649
Name:KVIDERA, CHRISTINE C (MSW, LICSW)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:C
Last Name:KVIDERA
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 1:7362 UNIVERSITY AVE NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3142
Mailing Address - Country:US
Mailing Address - Phone:763-503-3981
Mailing Address - Fax:763-503-3981
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:763-503-3981
Practice Address - Fax:763-503-3981
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN086791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN876857900Medicaid
MN8G623GROtherBCBS OF MN
MN876857900Medicaid