Provider Demographics
NPI:1689246076
Name:FENNEMA, CHRISTOPHER (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:FENNEMA
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2902
Mailing Address - Country:US
Mailing Address - Phone:182-821-1412
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:188-293-2352
Practice Address - Fax:218-829-1368
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25627104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker