Provider Demographics
NPI:1841202439
Name:ULRICH, MIRIAM GONZALEZ (MSW, LGSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:GONZALEZ
Last Name:ULRICH
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 123RD CIR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7096
Mailing Address - Country:US
Mailing Address - Phone:763-755-6470
Mailing Address - Fax:
Practice Address - Street 1:2401 123RD CIR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-7096
Practice Address - Country:US
Practice Address - Phone:763-755-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17958104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker