Provider Demographics
NPI:1245327584
Name:FONKERT, MARY SUE (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARY SUE
Middle Name:
Last Name:FONKERT
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 133
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-0133
Mailing Address - Country:US
Mailing Address - Phone:605-845-7938
Mailing Address - Fax:
Practice Address - Street 1:1309 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1146
Practice Address - Country:US
Practice Address - Phone:605-845-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD18521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD41548OtherMENTAL HEALTH PROVIDER
SD96869OtherMENTAL HEALTH PROVIDER
SD4996672OtherMENTAL HEALTH PROVIDER
SD177544OtherMENTAL HEALTH
SD6570960Medicaid
SD4996672OtherMENTAL HEALTH PROVIDER