Provider Demographics
NPI:1578655759
Name:KOSMAK, MICHELLE A (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:KOSMAK
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 1:8085 WAYZATA BLVD STE 101B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1468
Mailing Address - Country:US
Mailing Address - Phone:612-825-1559
Mailing Address - Fax:612-545-0100
Practice Address - Street 1:8085 WAYZATA BLVD STE 101B
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1468
Practice Address - Country:US
Practice Address - Phone:612-825-1559
Practice Address - Fax:612-545-0100
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN158781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN836108800Medicaid