Provider Demographics
NPI:1154744001
Name:ABDURRAZZAQ, KASIM (MSW LICSW)
Entity type:Individual
Prefix:
First Name:KASIM
Middle Name:
Last Name:ABDURRAZZAQ
Suffix:
Gender:M
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 MARSHALL AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6350
Mailing Address - Country:US
Mailing Address - Phone:651-329-6171
Mailing Address - Fax:651-340-9266
Practice Address - Street 1:1041 SELBY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6535
Practice Address - Country:US
Practice Address - Phone:612-813-5034
Practice Address - Fax:651-925-0044
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN199341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical