MEDICARE: KATHLEEN HEALTHCARE CENTER

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295213759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHLEEN HEALTHCARE CENTER

Provider Business Mailing Address
First Line	:	2647 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1187
Country	:	US
Telephone Number	:	612-345-7823
Fax Number	:

Provider Business Practice Location Address
First Line	:	2647 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1187
Country	:	US
Telephone Number	:	612-345-7823
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHLEEN MATTHEWS
Credential	:	LICSW
Telephone Number	:	612-978-3209

Provider Enumeration Date	:	08/06/2018
Last Update Date	:	08/06/2018

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