Healthcare Provider Details

I. General information

NPI: 1790289056
Provider Name (Legal Business Name): KIM LOUISE LAGRO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 03/09/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 6TH AVE E
DULUTH MN
55805-1952
US

IV. Provider business mailing address

2207 E. 5TH STREET
SUPERIOR WI
54880-3708
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-7000
  • Fax: 218-249-7050
Mailing address:
  • Phone: 715-256-8907
  • Fax: 715-256-8906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4686
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: