Provider Demographics
NPI:1629597323
Name:FIELDSTROM, KIRA LARSON (LICSW)
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:LARSON
Last Name:FIELDSTROM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KIRA
Other - Middle Name:
Other - Last Name:FIELDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3440 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407
Mailing Address - Country:US
Mailing Address - Phone:612-735-1253
Mailing Address - Fax:
Practice Address - Street 1:2400 BLAISDELL AVE.
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-516-5472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN258971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical