Provider Demographics
NPI:1851924245
Name:EHLERT, MARYBETH KIMBALL GAGE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:KIMBALL GAGE
Last Name:EHLERT
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WHITEWATER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4157
Mailing Address - Country:US
Mailing Address - Phone:952-999-6097
Mailing Address - Fax:
Practice Address - Street 1:12301 WHITEWATER DR STE 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-4157
Practice Address - Country:US
Practice Address - Phone:612-501-6279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN274321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical