Provider Demographics
NPI:1114375946
Name:PIERCE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PIERCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 SCENIC RD
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9312
Mailing Address - Country:US
Mailing Address - Phone:651-428-5970
Mailing Address - Fax:
Practice Address - Street 1:314 SCENIC RD
Practice Address - Street 2:
Practice Address - City:COLGATE
Practice Address - State:WI
Practice Address - Zip Code:53017
Practice Address - Country:US
Practice Address - Phone:651-428-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI1180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health