Healthcare Provider Details

I. General information

NPI: 1881792174
Provider Name (Legal Business Name): MARY ELLEN LOUISE VIDOVIC LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 HIGHWAY 96 E SUITE 200
WHITE BEAR LAKE MN
55110-3624
US

IV. Provider business mailing address

1310 HIGHWAY 96 E SUITE 200
WHITE BEAR LAKE MN
55110-3624
US

V. Phone/Fax

Practice location:
  • Phone: 651-426-3071
  • Fax:
Mailing address:
  • Phone: 651-426-3071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9587
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: