Provider Demographics
NPI:1619452521
Name:DUFFY, KATHLEEN J (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:DUFFY
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:J
Other - Last Name:BOORTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LICSW
Mailing Address - Street 1:4619 BRUNSWICK AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1016
Mailing Address - Country:US
Mailing Address - Phone:763-442-9819
Mailing Address - Fax:
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3765
Practice Address - Country:US
Practice Address - Phone:952-562-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN209841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical