Provider Demographics
NPI:1669461901
Name:MORIARTY, MARY K (LICSW, MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:LICSW, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17725 WEAVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1328
Mailing Address - Country:US
Mailing Address - Phone:763-494-8554
Mailing Address - Fax:769-494-8554
Practice Address - Street 1:4825 HIGHWAY 55
Practice Address - Street 2:SUITE 144
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-5147
Practice Address - Country:US
Practice Address - Phone:763-546-6718
Practice Address - Fax:763-546-6725
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3571041C0700X
MN56106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57B24MOOtherBLUECROSS INDIVIDUAL
MN6220253OtherMEDICA
MN87726OtherUNITED HEALTHCARE
MN106507OtherUCARE
MNN009275OtherCHAMPUS
MN0004274510OtherAETNA
MN40037OtherBEHAVIORAL HEALTHCARE
MN57B23MOOtherBLUECROSS
MN099373OtherMANAGED HEALTH NETWORK
MN54340OtherCIGNA
MN2815870OtherUNITED BEHAVIORAL HEALTH
MN33967OtherCERIDIAN