Provider Demographics
NPI:1528666898
Name:DAVISON-KERWOOD, IZAAK RIVER
Entity type:Individual
Prefix:
First Name:IZAAK
Middle Name:RIVER
Last Name:DAVISON-KERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 EWING AVE S APT 101
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4245
Mailing Address - Country:US
Mailing Address - Phone:612-274-5017
Mailing Address - Fax:
Practice Address - Street 1:13100 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1802
Practice Address - Country:US
Practice Address - Phone:952-206-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health