Provider Demographics
NPI:1326521337
Name:GOSSETT, MARY ANN (LGSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GOSSETT
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 19TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4807
Mailing Address - Country:US
Mailing Address - Phone:863-640-2663
Mailing Address - Fax:
Practice Address - Street 1:1811 WEIR DR STE 270
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-6741
Practice Address - Country:US
Practice Address - Phone:651-714-9646
Practice Address - Fax:651-714-9647
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health