Provider Demographics
NPI:1205928363
Name:MCDONALD, KERRY EDNA (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:EDNA
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:KERRY
Other - Middle Name:MCDONALD
Other - Last Name:MOKALLA, LICSW, LLC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5208 BLOOMINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-205-9745
Mailing Address - Fax:612-822-2116
Practice Address - Street 1:5208 BLOOMINGTON AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-205-9745
Practice Address - Fax:612-822-2116
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN139291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN924691600Medicaid