Provider Demographics
NPI:1063579936
Name:MARIAH, KATELYN (MA, LICSW)
Entity type:Individual
Prefix:MS
First Name:KATELYN
Middle Name:
Last Name:MARIAH
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 1:1641 HAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6236
Mailing Address - Country:US
Mailing Address - Phone:651-646-8306
Mailing Address - Fax:763-515-2442
Practice Address - Street 1:7600 BOONE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-4563
Practice Address - Country:US
Practice Address - Phone:763-515-2452
Practice Address - Fax:763-515-2442
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN073011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical