Provider Demographics
NPI:1912009242
Name:THALBERG, MARY VIOLA (MS, LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:VIOLA
Last Name:THALBERG
Suffix:
Gender:F
Credentials:MS, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15197 STATE HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444-8443
Mailing Address - Country:US
Mailing Address - Phone:320-894-4839
Mailing Address - Fax:
Practice Address - Street 1:15197 STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444-8443
Practice Address - Country:US
Practice Address - Phone:320-894-4839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical