=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043196397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA KOVENSKY MSW, LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2025
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10198 46TH PL NE
-----------------------------------------------------
City | SAINT MICHAEL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55376-3083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-497-0552
-----------------------------------------------------
Fax | 763-497-0552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 THIELEN DR
-----------------------------------------------------
City | SAINT MICHAEL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55376-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-515-4563
-----------------------------------------------------
Fax | 763-497-0552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 29459
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------