Provider Demographics
NPI:1831233055
Name:WILLIAMSEN, JOANNE MARIE (LP)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:MARIE
Last Name:WILLIAMSEN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 COUNTY ROAD 10
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3072
Mailing Address - Country:US
Mailing Address - Phone:763-560-8331
Mailing Address - Fax:763-560-8431
Practice Address - Street 1:3300 COUNTY ROAD 10
Practice Address - Street 2:SUITE 500
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3072
Practice Address - Country:US
Practice Address - Phone:763-560-8331
Practice Address - Fax:763-560-8431
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3939103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN436321300Medicaid