Healthcare Provider Details

I. General information

NPI: 1295078384
Provider Name (Legal Business Name): MARY KATHERINE NIEMISTO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3887 W BAATZ RD
MAPLE CITY MI
49664-9738
US

IV. Provider business mailing address

3887 W BAATZ RD
MAPLE CITY MI
49664-9738
US

V. Phone/Fax

Practice location:
  • Phone: 231-620-5365
  • Fax:
Mailing address:
  • Phone: 231-620-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801020404
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: