Provider Demographics
NPI:1528007333
Name:FOSSUM, MERLE (MSW)
Entity Type:Individual
Prefix:
First Name:MERLE
Middle Name:
Last Name:FOSSUM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7701 NORMANDALE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5310
Mailing Address - Country:US
Mailing Address - Phone:651-225-4675
Mailing Address - Fax:
Practice Address - Street 1:7701 NORMANDALE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5310
Practice Address - Country:US
Practice Address - Phone:651-225-4675
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54171041C0700X
MN99106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist