Provider Demographics
NPI:1366077828
Name:POGORELC, MARLA JACQUELINE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:JACQUELINE
Last Name:POGORELC
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 NE 3RD ST # 200H
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2869
Mailing Address - Country:US
Mailing Address - Phone:218-999-7081
Mailing Address - Fax:
Practice Address - Street 1:104 NE 3RD ST # 200H
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2869
Practice Address - Country:US
Practice Address - Phone:218-999-7081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26327101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional