Provider Demographics
NPI:1649547589
Name:MILLICENT, MARY DARLENE (LICSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DARLENE
Last Name:MILLICENT
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 1:11 1ST ST SE
Mailing Address - Street 2:PO BOX 32
Mailing Address - City:RICE
Mailing Address - State:MN
Mailing Address - Zip Code:56367-8857
Mailing Address - Country:US
Mailing Address - Phone:320-828-1092
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16030101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherNONE-PENDING