Provider Demographics
NPI:1639246952
Name:KNUDSON, LISA ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:KNUDSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8780 REFLECTIONS RD
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4003
Mailing Address - Country:US
Mailing Address - Phone:952-484-3509
Mailing Address - Fax:952-934-2147
Practice Address - Street 1:562 BAVARIA LN
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4597
Practice Address - Country:US
Practice Address - Phone:952-484-3509
Practice Address - Fax:952-934-2147
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10527104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4138228110Medicaid