1073590279 NPI number — MS. LYNN MARIE MARRS MSW LICSW

Table of content: HAYAT GASHAW TAHIR (NPI 1497221816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073590279 NPI number — MS. LYNN MARIE MARRS MSW LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRS
Provider First Name:
LYNN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LICSW
Provider Gender Code:
F

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:
1073590279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6347 UPLAND LN N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55311-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-202-9085
Provider Business Mailing Address Fax Number:
763-422-8283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6347 UPLAND LN N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55311-4005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-202-9085
Provider Business Practice Location Address Fax Number:
763-422-8283
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  10921 , 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: 115D3MA . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 215536200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1020748 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 152250 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 356S5MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-01251 . This is a "UBH (MEDICA)" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP24441 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6278216 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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