Provider Demographics
NPI:1609945286
Name:MCINERNEY, ELIZABETH ANNE (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MCINERNEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 SW 15TH AVENUE
Mailing Address - Street 2:PO BOX 504
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025
Mailing Address - Country:US
Mailing Address - Phone:651-464-2194
Mailing Address - Fax:
Practice Address - Street 1:882 SW 15TH AVENUE
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025
Practice Address - Country:US
Practice Address - Phone:651-464-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP39696Medicare UPIN
MN169L6MCMedicare UPIN