1053642652 NPI number — MRS. KATE ELIZABETH MATSON LICSW

Table of content: MRS. KATE ELIZABETH MATSON LICSW (NPI 1053642652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053642652 NPI number — MRS. KATE ELIZABETH MATSON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATSON
Provider First Name:
KATE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NOKLEBERG
Provider Other First Name:
KATE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053642652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1731 WEST . SUPERIOR STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-733-1331
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5095 FISH LAKE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-733-1331
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2010

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: 1041C0700X , with the licence number:  15442 , 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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