Provider Demographics
NPI:1588726806
Name:PALMER, MARY ANNA (LICSW, LMFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNA
Last Name:PALMER
Suffix:
Gender:F
Credentials:LICSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 CLIFF DR STE 112
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3335
Mailing Address - Country:US
Mailing Address - Phone:612-920-3745
Mailing Address - Fax:612-276-5740
Practice Address - Street 1:2121 CLIFF DR STE 112
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3335
Practice Address - Country:US
Practice Address - Phone:612-920-3745
Practice Address - Fax:612-276-5740
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4058101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN053858200Medicaid