Provider Demographics
NPI:1992888010
Name:CONNOLLY-PIUMBROECK, KATHLEEN (MSW, LICSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:CONNOLLY-PIUMBROECK
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:C
Other - Last Name:PIUMBROECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6255 WESSEL CT
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-1126
Mailing Address - Country:US
Mailing Address - Phone:952-949-0660
Mailing Address - Fax:
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:STE 320
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-928-1975
Practice Address - Fax:612-929-9006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN049211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1472721OtherMN TAX ID NUMBER