1801182837 NPI number — MARY MULLENBACH, PHD, LP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801182837 NPI number — MARY MULLENBACH, PHD, LP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY MULLENBACH, PHD, LP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LEGACY MENTAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801182837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6550 YORK AVE. S.
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6550 YORK AVE. S.
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-801-3316
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MULLENBACH
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
612-801-3316

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  4360 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1801192937 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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