Provider Demographics
NPI:1073611729
Name:NETTLETON, MARY ROSE (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:NETTLETON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2619
Mailing Address - Country:US
Mailing Address - Phone:612-825-4407
Mailing Address - Fax:612-825-0768
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 209
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:612-825-4407
Practice Address - Fax:612-825-0768
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10269104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker