Provider Demographics
NPI:1639835473
Name:PRIDEMORE, ANNETTE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:FATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16077 BAYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S STE 402
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2142
Practice Address - Country:US
Practice Address - Phone:612-274-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN277411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical