Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | LP4979 | MN |
Y | 103G00000X | Clinical Psychologist | LP4979 | MN |
Y | 103TC0700X | Clinical Psychologist | LP4979 | MN |
NPI | 1013357797 |
---|---|
Provider Name | Dr. Kari Michelle-Ferber Maynard |
First Address | Pine City, MN 55063-1505 |
Second Address | Pine City, MN 55063-1505 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2013 |
Last Update Date | 03/09/2015 |