=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700317062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM MARCIA SANOW LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2017
-----------------------------------------------------
Last Update Date | 03/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 N HIGH ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-1471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-537-4525
-----------------------------------------------------
Fax | 507-929-4673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2841 170TH ST
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56175-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-530-3833
-----------------------------------------------------
Fax | 507-929-4673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 3433
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------