Provider Demographics
NPI:1740642214
Name:ELISON, KATHRYN (LICSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:ELISON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 DELAWARE ST SE
Mailing Address - Street 2:MAIL CODE 1932
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2959
Mailing Address - Country:US
Mailing Address - Phone:704-707-6681
Mailing Address - Fax:
Practice Address - Street 1:2512 S 7TH ST
Practice Address - Street 2:PEDIATRIC SPECIALTY CLINIC
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1404
Practice Address - Country:US
Practice Address - Phone:612-365-6777
Practice Address - Fax:612-365-8001
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN230631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical