Healthcare Provider Details

I. General information

NPI: 1578666590
Provider Name (Legal Business Name): ANN CATHERINE WHEATON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BROAD ST STE 200
MANKATO MN
56001-3569
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 507-225-1500
  • Fax: 507-225-1501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12600
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier383633900
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
Identifier533G9WH
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: