Healthcare Provider Details

I. General information

NPI: 1104329234
Provider Name (Legal Business Name): MARY ELIZABETH MARESH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

IV. Provider business mailing address

2215 E LAKE ST
MINNEAPOLIS MN
55407-4385
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-9438
  • Fax:
Mailing address:
  • Phone: 612-596-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP6224
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: