Provider Demographics
NPI:1841774635
Name:ROWENHORST, RUSSELL (LICSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:ROWENHORST
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-2205
Mailing Address - Country:US
Mailing Address - Phone:218-428-9829
Mailing Address - Fax:
Practice Address - Street 1:1103 AVENUE B
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1638
Practice Address - Country:US
Practice Address - Phone:218-878-2574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6241104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker