Provider Demographics
NPI:1184746133
Name:THOMAS, MARY BETH (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:THOMAS
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 1:207 AVENUE C
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1584
Mailing Address - Country:US
Mailing Address - Phone:218-655-3347
Mailing Address - Fax:
Practice Address - Street 1:207 AVENUE C
Practice Address - Street 2:SUITE 202
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1584
Practice Address - Country:US
Practice Address - Phone:218-655-3347
Practice Address - Fax:218-655-3390
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN128491041C0700X
CO9930741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800001494OtherMEDICARE
MN766160600Medicaid
MN800001494Medicare ID - Type Unspecified