MEDICARE: MARIE RIDGEWAY 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
1	1041C0700X	Clinical Social Worker	20207	MN

General Provider Information

NPI Number	:	1376904359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE RIDGEWAY LICSW

Provider Business Mailing Address
First Line	:	1409 WILLOW ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3254
Country	:	US
Telephone Number	:	612-314-9169
Fax Number	:

Provider Business Practice Location Address
First Line	:	1409 WILLOW ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3254
Country	:	US
Telephone Number	:	612-314-9169
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2016
Last Update Date	:	07/21/2022

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Directions to “ MARIE RIDGEWAY LICSW” Practice Location

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