Provider Demographics
NPI:1023166659
Name:GALES-WENZ, MARY MARGARET (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:GALES-WENZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:9075 QUADAY AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6672
Practice Address - Country:US
Practice Address - Phone:763-746-9492
Practice Address - Fax:763-746-3685
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN045181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002085Medicare Oscar/Certification