Provider Demographics
NPI:1669021895
Name:WIDSETH, MARY LYNN (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:WIDSETH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 22ND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2503
Mailing Address - Country:US
Mailing Address - Phone:320-250-7997
Mailing Address - Fax:
Practice Address - Street 1:2700 1ST ST N # 204
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4256
Practice Address - Country:US
Practice Address - Phone:320-250-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty