MEDICARE: LAURA JEANNE NIEWALD

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80G34NI	OTHER	MN	BCBS OF MN INDIVID. #
2	478932600	OTHER	MN	MN HEALTH CARE PROGRAMS
3	80G24CL	OTHER	MN	BCBS OF MN CLINIC #

General Provider Information

NPI Number	:	1831250174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAURA JEANNE NIEWALD

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	:	OWNER
Name	:	LAURA JEANNE NIEWALD
Credential	:	MA, LMFT
Telephone Number	:	612-929-1500

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	06/16/2008

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