Provider Demographics
NPI:1043722770
Name:KNUTSON, MARY CATHERINE (APRN/PMHCNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:APRN/PMHCNS
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2228
Mailing Address - Country:US
Mailing Address - Phone:217-210-2353
Mailing Address - Fax:
Practice Address - Street 1:1201 S 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2228
Practice Address - Country:US
Practice Address - Phone:217-210-2353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015968363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty