Provider Demographics
NPI:1588370225
Name:UNDIS, MARYANN (LADC)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:UNDIS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2250
Mailing Address - Country:US
Mailing Address - Phone:612-874-9811
Mailing Address - Fax:612-874-9820
Practice Address - Street 1:2200 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2250
Practice Address - Country:US
Practice Address - Phone:612-874-9811
Practice Address - Fax:612-874-9820
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301953101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)