Provider Demographics
NPI:1932470127
Name:JOHANNECK, CATHERINE ROSE (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ROSE
Last Name:JOHANNECK
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 1:7362 UNIVERSITY AVE NE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3152
Mailing Address - Country:US
Mailing Address - Phone:763-503-3981
Mailing Address - Fax:763-503-3981
Practice Address - Street 1:7362 UNIVERSITY AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3152
Practice Address - Country:US
Practice Address - Phone:763-503-3981
Practice Address - Fax:763-503-3981
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN179891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1932470127OtherCAQH-UBH
MN1932470127Medicaid
1932470127OtherMCC