Basic Information
| Provider Information | |||||||||
| NPI: | 1154754984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVARD | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAMM | ||||||||
| OtherFirstName: | JEAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 621 W LAKE ST | ||||||||
| Address2: | STE 350 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554082952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129792276 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 W SUPERIOR ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558021808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187224379 | ||||||||
| FaxNumber: | 2187224333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2013 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12047 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.