Provider Demographics
NPI:1629787478
Name:KABITZ, CARLY L (LICSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:L
Last Name:KABITZ
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 1:2308 AUERBACH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4724
Mailing Address - Country:US
Mailing Address - Phone:651-300-9897
Mailing Address - Fax:
Practice Address - Street 1:2308 AUERBACH ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4724
Practice Address - Country:US
Practice Address - Phone:651-300-9897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN289641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty