Provider Demographics
NPI:1831149145
Name:SERUM, VICKI J (MA, LICSW)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:J
Last Name:SERUM
Suffix:
Gender:F
Credentials:MA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7352 OJIBWA RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7039
Mailing Address - Country:US
Mailing Address - Phone:218-963-2670
Mailing Address - Fax:
Practice Address - Street 1:13073 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-7443
Practice Address - Country:US
Practice Address - Phone:218-851-3813
Practice Address - Fax:218-824-9507
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6699LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical