Healthcare Provider Details

I. General information

NPI: 1124208715
Provider Name (Legal Business Name): KATHOUCHA EDOUARD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 LEXINGTON AVE N
ARDEN HILLS MN
55126-6164
US

IV. Provider business mailing address

14301 EWING AVE S
BURNSVILLE MN
55306-4885
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-5350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number069349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: