Provider Demographics
NPI:1841448636
Name:GOULET, MARYJEAN (MSED)
Entity type:Individual
Prefix:MS
First Name:MARYJEAN
Middle Name:
Last Name:GOULET
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1170
Mailing Address - Country:US
Mailing Address - Phone:218-726-2244
Mailing Address - Fax:218-725-5186
Practice Address - Street 1:320 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1404
Practice Address - Country:US
Practice Address - Phone:218-726-2244
Practice Address - Fax:218-725-5186
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0352103T00000X
MN60131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist