Healthcare Provider Details

I. General information

NPI: 1275941775
Provider Name (Legal Business Name): NEFERTITI K KHEMET GOUDJAYI LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5329 48TH AVE S UNIT 128
MINNEAPOLIS MN
55417-3701
US

IV. Provider business mailing address

5329 48TH AVE S UNIT 128
MINNEAPOLIS MN
55417-3701
US

V. Phone/Fax

Practice location:
  • Phone: 916-243-5337
  • Fax:
Mailing address:
  • Phone: 916-243-5337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32064
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61311533
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: