MEDICARE: MARY ELLEN LOUISE VIDOVIC 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	104100000X	Social Worker	9587	MN

General Provider Information

NPI Number	:	1881792174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN LOUISE VIDOVIC LICSW

Provider Business Mailing Address
First Line	:	1310 HIGHWAY 96 E
Second Line	:	SUITE 200
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3624
Country	:	US
Telephone Number	:	651-426-3071
Fax Number	:

Provider Business Practice Location Address
First Line	:	1310 HIGHWAY 96 E
Second Line	:	SUITE 200
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3624
Country	:	US
Telephone Number	:	651-426-3071
Fax Number	:

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	04/10/2008

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