Provider Demographics
NPI:1730832833
Name:ERVASTI, KACIE E (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:E
Last Name:ERVASTI
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7432 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3955
Mailing Address - Country:US
Mailing Address - Phone:612-616-9063
Mailing Address - Fax:
Practice Address - Street 1:1619 DAYTON AVE STE 325
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6495
Practice Address - Country:US
Practice Address - Phone:612-616-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1760892244Medicaid