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NPI Code Detail

MEDICARE: MS. KATELYN MARIAH M.A, LICSW

MEDICARE: MS. KATELYN MARIAH M.A, LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker07301MN

General Provider Information

NPI Number : 1063579936
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KATELYN MARIAH M.A, LICSW
Provider Business Mailing Address
First Line : 1641 HAGUE AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55104-6236
Country : US
Telephone Number : 651-646-8306
Fax Number : 763-515-2442
Provider Business Practice Location Address
First Line : 7600 BOONE AVE N
Second Line :
City : BROOKLYN PARK
State : MN
Zip : 55428-4563
Country : US
Telephone Number : 763-515-2452
Fax Number : 763-515-2442
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/02/2007
Last Update Date : 07/08/2007

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