Healthcare Provider Details

I. General information

NPI: 1336280619
Provider Name (Legal Business Name): NICOLE S. UZENDOSKI MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 GRAND AVE
SAINT PAUL MN
55105-3002
US

IV. Provider business mailing address

1061 GRAND AVE
SAINT PAUL MN
55105-3002
US

V. Phone/Fax

Practice location:
  • Phone: 651-212-4920
  • Fax:
Mailing address:
  • Phone: 612-644-0415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number17773
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: