Provider Demographics
NPI:1083587075
Name:ELAINE, MARIE MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:MARIE
Last Name:ELAINE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2069 WATSON AVE APT 32
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1116
Mailing Address - Country:US
Mailing Address - Phone:952-393-9660
Mailing Address - Fax:
Practice Address - Street 1:2069 WATSON AVE APT 32
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1116
Practice Address - Country:US
Practice Address - Phone:952-393-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24782101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty