Healthcare Provider Details

I. General information

NPI: 1568756302
Provider Name (Legal Business Name): VIVIANE MARIE ZASTROW LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 98TH ST STE 107
BLOOMINGTON MN
55420-4858
US

IV. Provider business mailing address

18986 LAKE DR E
CHANHASSEN MN
55317-9348
US

V. Phone/Fax

Practice location:
  • Phone: 612-968-6297
  • Fax: 612-435-9842
Mailing address:
  • Phone: 952-401-4869
  • Fax: 952-474-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17078
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: