MEDICARE: KASIM ABDURRAZZAQ MSW LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	19934	MN

General Provider Information

NPI Number	:	1154744001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASIM ABDURRAZZAQ MSW LICSW

Provider Business Mailing Address
First Line	:	1437 MARSHALL AVE
Second Line	:	SUITE 102
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6350
Country	:	US
Telephone Number	:	651-329-6171
Fax Number	:	651-340-9266

Provider Business Practice Location Address
First Line	:	1041 SELBY AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6535
Country	:	US
Telephone Number	:	612-813-5034
Fax Number	:	651-925-0044

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2014
Last Update Date	:	08/12/2016

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