Provider Demographics
NPI:1760735682
Name:NISSEN, MARY KATHERINE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:NISSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559
Mailing Address - Country:US
Mailing Address - Phone:907-543-6100
Mailing Address - Fax:907-543-6008
Practice Address - Street 1:407 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2710
Practice Address - Country:US
Practice Address - Phone:406-210-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1895601041C0700X
MT664381041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid