MEDICARE: MARYANNE QUACKENBUSH 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	04051	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538198494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYANNE QUACKENBUSH LICSW

Provider Business Mailing Address
First Line	:	1401 EAST FIRST STREET
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55805
Country	:	US
Telephone Number	:	218-728-4404
Fax Number	:	218-728-4404

Provider Business Practice Location Address
First Line	:	215 N CENTRAL AVE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55807-2402
Country	:	US
Telephone Number	:	218-624-5683
Fax Number	:	218-624-5736

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

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	05/23/2012

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