Healthcare Provider Details

I. General information

NPI: 1760735682
Provider Name (Legal Business Name): MARY KATHERINE NISSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MAIN ST SW
RONAN MT
59864-2710
US

IV. Provider business mailing address

PO BOX 528
BETHEL AK
99559
US

V. Phone/Fax

Practice location:
  • Phone: 406-210-8831
  • Fax:
Mailing address:
  • Phone: 907-543-6100
  • Fax: 907-543-6008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number189560
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number66438
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: