Provider Demographics
NPI:1518966787
Name:WAHLBERG, MARY CLAIRE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CLAIRE
Last Name:WAHLBERG
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 1:408 SAINT PETER ST
Mailing Address - Street 2:SUITE 429
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1130
Mailing Address - Country:US
Mailing Address - Phone:651-224-0614
Mailing Address - Fax:651-224-5754
Practice Address - Street 1:408 SAINT PETER ST
Practice Address - Street 2:SUITE 429
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1130
Practice Address - Country:US
Practice Address - Phone:651-224-0614
Practice Address - Fax:651-224-5754
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
29271WAOtherBC/BS
107385OtherU CARE
62-20851OtherMEDICA
R64539Medicare UPIN