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NPI Code Detail

MEDICARE: ANNETTE PRIDEMORE MSW, LICSW

MEDICARE: ANNETTE PRIDEMORE MSW, 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 Worker27741MN

General Provider Information

NPI Number : 1639835473
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANNETTE PRIDEMORE MSW, LICSW
Provider Business Mailing Address
First Line : 16077 BAYWOOD LN
Second Line :
City : EDEN PRAIRIE
State : MN
Zip : 55346-2409
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6363 FRANCE AVE S STE 402
Second Line :
City : EDINA
State : MN
Zip : 55435-2142
Country : US
Telephone Number : 612-274-7570
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/16/2021
Last Update Date : 11/16/2021

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