1669461901 NPI number — MARY K MORIARTY LICSW, MFT

Table of content: MARY K MORIARTY LICSW, MFT (NPI 1669461901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669461901 NPI number — MARY K MORIARTY LICSW, MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORIARTY
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW, MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669461901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17725 WEAVER LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55311-1328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-494-8554
Provider Business Mailing Address Fax Number:
769-494-8554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4825 HIGHWAY 55
Provider Second Line Business Practice Location Address:
SUITE 144
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-5147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-546-6718
Provider Business Practice Location Address Fax Number:
763-546-6725
Provider Enumeration Date:
10/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  357 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 56 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 57B24MO . This is a "BLUECROSS INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6220253 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 87726 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 106507 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: N009275 . This is a "CHAMPUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0004274510 . This is a "AETNA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 40037 . This is a "BEHAVIORAL HEALTHCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 57B23MO . This is a "BLUECROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 099373 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 54340 . This is a "CIGNA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2815870 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 33967 . This is a "CERIDIAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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