Provider Demographics
NPI:1790431195
Name:KEZY, PAMERA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:PAMERA
Middle Name:
Last Name:KEZY
Suffix:
Gender:F
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 1:4816 ENSIGN AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4437
Mailing Address - Country:US
Mailing Address - Phone:612-868-2614
Mailing Address - Fax:
Practice Address - Street 1:5700 BOTTINEAU BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3183
Practice Address - Country:US
Practice Address - Phone:844-697-8766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN266701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical