Healthcare Provider Details

I. General information

NPI: 1083942387
Provider Name (Legal Business Name): KILEY CHRISTINE KROCAK MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 W BROADWAY AVE
MINNEAPOLIS MN
55411-2533
US

IV. Provider business mailing address

1250 W BROADWAY AVE
MINNEAPOLIS MN
55411-2533
US

V. Phone/Fax

Practice location:
  • Phone: 612-688-0254
  • Fax:
Mailing address:
  • Phone: 612-688-0254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number16033
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: