Provider Demographics
NPI:1700554797
Name:ROTEL, KRISTINE MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARIE
Last Name:ROTEL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:ONGSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:425 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-4400
Mailing Address - Country:US
Mailing Address - Phone:612-332-4973
Mailing Address - Fax:612-238-3534
Practice Address - Street 1:425 20TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-4400
Practice Address - Country:US
Practice Address - Phone:612-332-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21360101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health