Provider Demographics
NPI:1386156123
Name:TOMHAVE, KERRY CLARK (LICSW)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:CLARK
Last Name:TOMHAVE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 N 3RD AVE W STE 310
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1614
Mailing Address - Country:US
Mailing Address - Phone:218-722-2368
Mailing Address - Fax:
Practice Address - Street 1:5 N 3RD AVE W STE 310
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1614
Practice Address - Country:US
Practice Address - Phone:218-722-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN236901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical