Provider Demographics
NPI:1912092263
Name:CAVALLI, KRISTINA S (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:S
Last Name:CAVALLI
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 1:1407 24TH AVE S
Mailing Address - Street 2:STE. 530
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6761
Mailing Address - Country:US
Mailing Address - Phone:701-738-0888
Mailing Address - Fax:701-738-0889
Practice Address - Street 1:1407 24TH AVE S
Practice Address - Street 2:STE. 530
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6761
Practice Address - Country:US
Practice Address - Phone:701-738-0888
Practice Address - Fax:701-738-0889
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND37561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19108Medicaid