1568425908 NPI number — DR. MARK R THELEN PSYD LP LMFT

Table of content: DIMARA ROSADO-GONZALEZ (NPI 1205563707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568425908 NPI number — DR. MARK R THELEN PSYD LP LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THELEN
Provider First Name:
MARK
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD LP LMFT
Provider Gender Code:
M

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:
1568425908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55362-0102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-370-0243
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 E BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55362-9317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-370-0243
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2006

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: 106H00000X , with the licence number:  645 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: LP2992 , 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: 6118960 . This is a "UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 105008 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP27417 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1023459 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 680007902 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 704817300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7H446TH . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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