MEDICARE: LAURA JEANNE NIEWALD M.A., LMFT

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	106H00000X	Marriage & Family Therapist	1216	MN

General Provider Information

NPI Number	:	1366517443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JEANNE NIEWALD M.A., LMFT

Provider Business Mailing Address
First Line	:	4317 UPTON AVE S
Second Line	:	SUITE C
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-1539
Country	:	US
Telephone Number	:	612-929-1500
Fax Number	:	612-929-1500

Provider Business Practice Location Address
First Line	:	4317 UPTON AVE S
Second Line	:	SUITE C
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-1539
Country	:	US
Telephone Number	:	612-929-1500
Fax Number	:	612-929-1500

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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