Healthcare Provider Details

I. General information

NPI: 1467829168
Provider Name (Legal Business Name): PPSM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
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: 651-212-4920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17773
License Number StateMN

VIII. Authorized Official

Name: NICOLE UZENDOSKI
Title or Position: LICSW
Credential:
Phone: 612-644-0415