Provider Demographics
NPI:1538198494
Name:QUACKENBUSH, MARYANNE (LICSW)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MARYANNE
Other - Middle Name:
Other - Last Name:LINDLIEF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4404
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:215 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2402
Practice Address - Country:US
Practice Address - Phone:218-624-5683
Practice Address - Fax:218-624-5736
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN040511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN333357400Medicaid
MN800001198Medicare ID - Type Unspecified