Provider Demographics
NPI:1619138633
Name:ETHEN, MARY JOANNE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOANNE
Last Name:ETHEN
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 1:361 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-7086
Mailing Address - Country:US
Mailing Address - Phone:651-326-3675
Mailing Address - Fax:651-232-3494
Practice Address - Street 1:69 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1004
Practice Address - Country:US
Practice Address - Phone:651-326-3675
Practice Address - Fax:651-232-3494
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN173611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical