Provider Demographics
NPI:1285462937
Name:PEART, MADELINE ROSE (LICSW)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:PEART
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 1:303 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3681
Mailing Address - Country:US
Mailing Address - Phone:218-322-4101
Mailing Address - Fax:
Practice Address - Street 1:413 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-0015
Practice Address - Country:US
Practice Address - Phone:218-999-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN823091041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool