Provider Demographics
NPI:1912729427
Name:SEABLOOM, MARY (LP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SEABLOOM
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W SUPERIOR ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1818
Mailing Address - Country:US
Mailing Address - Phone:218-481-7660
Mailing Address - Fax:218-216-1452
Practice Address - Street 1:306 W SUPERIOR ST STE 1000
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1818
Practice Address - Country:US
Practice Address - Phone:218-481-7660
Practice Address - Fax:218-216-1452
Is Sole Proprietor?:No
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical