Provider Demographics
NPI:1154533578
Name:NEZNIK, MARY KATHLEEN (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:NEZNIK
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 1:2375 UNIVERSITY AVE W
Mailing Address - Street 2:#160
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1631
Mailing Address - Country:US
Mailing Address - Phone:651-642-1709
Mailing Address - Fax:651-642-0150
Practice Address - Street 1:2375 UNIVERSITY AVE W
Practice Address - Street 2:#160
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1631
Practice Address - Country:US
Practice Address - Phone:651-642-1709
Practice Address - Fax:651-642-0150
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN85121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical