Basic Information
| Provider Information | |||||||||
| NPI: | 1548326937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LADD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CASEY | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284491 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186245683 | ||||||||
| FaxNumber: | 2186245736 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 09/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 293 | MN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | 4937 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 081757100 | 05 | MN | MEDICAID |