MEDICARE: MS. MARY E TOMES LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6705	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6201899	OTHER	MN	UNITED BEHAVIORAL HEALTH
2	37A79ME	OTHER	MN	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1144307406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY E TOMES LICSW

Provider Business Mailing Address
First Line	:	4049 GRAND AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55409-1536
Country	:	US
Telephone Number	:	651-659-2961
Fax Number	:	651-645-7307

Provider Business Practice Location Address
First Line	:	1821 UNIVERSITY AVE W
Second Line	:	SUITE N-464
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-2801
Country	:	US
Telephone Number	:	651-659-2961
Fax Number	:	651-645-7307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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Directions to “ MS. MARY E TOMES LICSW” Practice Location

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