Provider Demographics
NPI:1790057636
Name:RIAD, MARTHA JOHANNA (LICSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JOHANNA
Last Name:RIAD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:JOHANNA
Other - Last Name:ALWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:7160 CAHILL RD
Mailing Address - Street 2:APT 227
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2046
Mailing Address - Country:US
Mailing Address - Phone:860-212-7974
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN193011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical