Provider Demographics
NPI:1881792174
Name:VIDOVIC, MARY ELLEN LOUISE (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN LOUISE
Last Name:VIDOVIC
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 1:1310 HIGHWAY 96 E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3624
Mailing Address - Country:US
Mailing Address - Phone:651-426-3071
Mailing Address - Fax:
Practice Address - Street 1:1310 HIGHWAY 96 E
Practice Address - Street 2:SUITE 200
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3624
Practice Address - Country:US
Practice Address - Phone:651-426-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9587104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker