Provider Demographics
NPI:1790503704
Name:IZAAK DAVISON-KERWOOD
Entity type:Organization
Organization Name:IZAAK DAVISON-KERWOOD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IZAAK
Authorized Official - Middle Name:RIVER
Authorized Official - Last Name:DAVISON-KERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:612-850-1006
Mailing Address - Street 1:1713 TYLER ST NE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1533
Mailing Address - Country:US
Mailing Address - Phone:612-850-1006
Mailing Address - Fax:
Practice Address - Street 1:1713 TYLER ST NE UNIT 2
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1533
Practice Address - Country:US
Practice Address - Phone:612-850-1006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty