Basic Information
| Provider Information | |||||||||
| NPI: | 1073933859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ICE | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROGERS | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2430 NICOLLET AVE | ||||||||
| Address2: | 2430 NICOLLET AVE SOUTH | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554043461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711454 | ||||||||
| FaxNumber: | 6128711505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554051430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711454 | ||||||||
| FaxNumber: | 6128711505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 21054 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.