MEDICARE: MARY LOUISE HARLOW PSYD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist	LP4420	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154490258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOUISE HARLOW PSYD, LP

Provider Business Mailing Address
First Line	:	2775 THOMAS AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4346
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 W LAKE ST
Second Line	:	#320
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4527
Country	:	US
Telephone Number	:	612-922-6578
Fax Number	:	612-929-9006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	06/04/2010

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