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NPI Code Detail

MEDICARE: MS. MARY CLAIRE WAHLBERG LICSW

MEDICARE: MS. MARY CLAIRE WAHLBERG 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
11041C0700XClinical Social Worker1745MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
129271WAOTHERBC/BS
2107385OTHERU CARE
362-20851OTHERMEDICA

General Provider Information

NPI Number : 1518966787
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARY CLAIRE WAHLBERG LICSW
Provider Business Mailing Address
First Line : 408 SAINT PETER ST
Second Line : SUITE 429
City : SAINT PAUL
State : MN
Zip : 55102-1130
Country : US
Telephone Number : 651-224-0614
Fax Number : 651-224-5754
Provider Business Practice Location Address
First Line : 408 SAINT PETER ST
Second Line : SUITE 429
City : SAINT PAUL
State : MN
Zip : 55102-1130
Country : US
Telephone Number : 651-224-0614
Fax Number : 651-224-5754
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2005
Last Update Date : 07/08/2007

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