Provider Demographics
NPI:1770712713
Name:MELANDER, MARYJO (LICSW)
Entity type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:MELANDER
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 1:1960 CLIFF LAKE ROAD
Mailing Address - Street 2:SUITE 129-179
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122
Mailing Address - Country:US
Mailing Address - Phone:651-505-5349
Mailing Address - Fax:
Practice Address - Street 1:1960 CLIFF LAKE ROAD
Practice Address - Street 2:SUITE 129-179
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:651-505-5349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW 17391104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker