Healthcare Provider Details

I. General information

NPI: 1790431195
Provider Name (Legal Business Name): PAMERA KEZY MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 BOTTINEAU BLVD
CRYSTAL MN
55429-3183
US

IV. Provider business mailing address

4816 ENSIGN AVE N
NEW HOPE MN
55428-4437
US

V. Phone/Fax

Practice location:
  • Phone: 844-697-8766
  • Fax:
Mailing address:
  • Phone: 612-868-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26670
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: