MEDICARE: MS. KATHLEEN CONNOLLY-PIUMBROECK 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	04921	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1472721	OTHER	MN	MN TAX ID NUMBER

General Provider Information

NPI Number	:	1992888010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN CONNOLLY-PIUMBROECK MSW, LICSW

Provider Business Mailing Address
First Line	:	6255 WESSEL CT
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55346-1126
Country	:	US
Telephone Number	:	952-949-0660
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 W LAKE ST
Second Line	:	STE 320
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4527
Country	:	US
Telephone Number	:	612-928-1975
Fax Number	:	612-929-9006

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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