Provider Demographics
NPI:1992242762
Name:KURNIAWAN, MARY E (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:KURNIAWAN
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7375
Mailing Address - Country:US
Mailing Address - Phone:605-755-8110
Mailing Address - Fax:605-755-0707
Practice Address - Street 1:915 MT VIEW RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3414
Practice Address - Country:US
Practice Address - Phone:605-755-7300
Practice Address - Fax:605-755-0707
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD34971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical