Provider Demographics
NPI:1487283644
Name:MICHELLE A KOSMAK LICSW LLC
Entity type:Organization
Organization Name:MICHELLE A KOSMAK LICSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSMAK
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-825-1559
Mailing Address - Street 1:8085 WAYZATA BLVD STE 101B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1468
Mailing Address - Country:US
Mailing Address - Phone:612-825-1559
Mailing Address - Fax:612-545-0100
Practice Address - Street 1:8085 WAYZATA BLVD STE 101B
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1468
Practice Address - Country:US
Practice Address - Phone:612-825-1559
Practice Address - Fax:612-545-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty