Healthcare Provider Details

I. General information

NPI: 1518140391
Provider Name (Legal Business Name): RON JOSEPH ZUCHORA-WALSKE CLINICALSOCIALWORKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RON JOSEPH ZUCHORA-WALSKE LPC

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5939 PORTLAND AVE SOUTH
MINNEAPOLIS MN
55417
US

IV. Provider business mailing address

5733 14TH AVE SOUTH
MINNEAPOLIS MN
55417-1001
US

V. Phone/Fax

Practice location:
  • Phone: 612-689-4444
  • Fax: 612-254-8244
Mailing address:
  • Phone: 612-719-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24636
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: