Provider Demographics
NPI:1891103255
Name:KUSTANOWITZ, KASHMIR (LCSW)
Entity Type:Individual
Prefix:
First Name:KASHMIR
Middle Name:
Last Name:KUSTANOWITZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KASHMIR
Other - Middle Name:ROSE
Other - Last Name:WOOD-KUSTANOWITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:1100 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1430
Practice Address - Country:US
Practice Address - Phone:612-871-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
CA798081041C0700X
MN296741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891103255Medicaid