Provider Demographics
NPI:1740784859
Name:IWATA, CASIE (MSW, LICW)
Entity Type:Individual
Prefix:
First Name:CASIE
Middle Name:
Last Name:IWATA
Suffix:
Gender:F
Credentials:MSW, LICW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 FORD PKWY # 5481
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2850
Mailing Address - Country:US
Mailing Address - Phone:612-466-0315
Mailing Address - Fax:
Practice Address - Street 1:2136 FORD PKWY # 5481
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2850
Practice Address - Country:US
Practice Address - Phone:612-466-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
226171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1740784859Medicaid