1992810303 NPI number — MARSHA MCDONALD, MSW, LICSW, LLC

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 1992810303 NPI number — MARSHA MCDONALD, MSW, LICSW, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARSHA MCDONALD, MSW, LICSW, LLC
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:
Provider Other Organization Name Type Code:
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:
1992810303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4005 W 65TH ST
Provider Second Line Business Mailing Address:
122
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-285-2917
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4005 W 65TH ST
Provider Second Line Business Practice Location Address:
122
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-285-2917
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONALD
Authorized Official First Name:
MARSHA
Authorized Official Middle Name:
BERNADETTE
Authorized Official Title or Position:
CHIEF MANAGER, TREASURER AND SECRET
Authorized Official Telephone Number:
952-285-2917

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  14892 , 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: 258P4MC . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6271149 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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