1679628192 NPI number — MANKATO PSYCHOLOGY CLINIC, PLC

Table of content: (NPI 1679628192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679628192 NPI number — MANKATO PSYCHOLOGY CLINIC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANKATO PSYCHOLOGY CLINIC, PLC
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:
1679628192
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:
209 S 2ND ST
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
MANKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56001-3626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-387-1350
Provider Business Mailing Address Fax Number:
507-387-6605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 S 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-387-1350
Provider Business Practice Location Address Fax Number:
507-387-6605
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HESSE
Authorized Official First Name:
PEGGYSUE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PARTNER
Authorized Official Telephone Number:
507-387-1350

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1926616 , 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: 81G62MA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114490 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6H521MA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6H520MA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 155H1MA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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