Provider Demographics
NPI:1770900508
Name:CHASE, KRISTLE ANN (LICSW)
Entity type:Individual
Prefix:
First Name:KRISTLE
Middle Name:ANN
Last Name:CHASE
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 1:1300 WILLMAR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4737
Mailing Address - Country:US
Mailing Address - Phone:320-221-1419
Mailing Address - Fax:
Practice Address - Street 1:1300 WILLMAR AVE SE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4737
Practice Address - Country:US
Practice Address - Phone:320-221-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN186911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical