=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144307406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY E TOMES LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1821 UNIVERSITY AVE W SUITE N-464
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-659-2961
-----------------------------------------------------
Fax | 651-645-7307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4049 GRAND AVE S
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55409-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-659-2961
-----------------------------------------------------
Fax | 651-645-7307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6705
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------