Provider Demographics
NPI:1093128233
Name:SWENSON, MARY THERESA (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:THERESA
Last Name:SWENSON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THERESA
Other - Last Name:DUREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:13750 CROSSTOWN DR NW
Mailing Address - Street 2:MOLLY PROFESSIONAL CENTER PHASE II SUITE 207
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304
Mailing Address - Country:US
Mailing Address - Phone:763-755-6290
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR PHASE II
Practice Address - Street 2:SUITE 207
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-2664
Practice Address - Country:US
Practice Address - Phone:763-413-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00808101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01405OtherSTATE LICENSE