MEDICARE: MARY KATHERINE NIEMISTO MSW

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	6801020404	MI

General Provider Information

NPI Number	:	1295078384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHERINE NIEMISTO MSW

Provider Business Mailing Address
First Line	:	3887 W BAATZ RD
Second Line	:
City	:	MAPLE CITY
State	:	MI
Zip	:	49664-9738
Country	:	US
Telephone Number	:	231-620-5365
Fax Number	:

Provider Business Practice Location Address
First Line	:	3887 W BAATZ RD
Second Line	:
City	:	MAPLE CITY
State	:	MI
Zip	:	49664-9738
Country	:	US
Telephone Number	:	231-620-5365
Fax Number	:

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

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/27/2013

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