1013201847 NPI number — MRS. KATHLEEN ROSE-PENKALA MASSMANN LPCC AND M,S.

Table of content: MRS. KATHLEEN ROSE-PENKALA MASSMANN LPCC AND M,S. (NPI 1013201847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013201847 NPI number — MRS. KATHLEEN ROSE-PENKALA MASSMANN LPCC AND M,S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSMANN
Provider First Name:
KATHLEEN
Provider Middle Name:
ROSE-PENKALA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPCC AND M,S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013201847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 S CEDAR STREET
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
MONTICELO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-208-9533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9766 FALLON AVE NE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55362-4589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
637-323-3517
Provider Business Practice Location Address Fax Number:
763-322-5026
Provider Enumeration Date:
06/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  305 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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