Healthcare Provider Details

I. General information

NPI: 1972649846
Provider Name (Legal Business Name): MARY KATHERINE VERKENNES M.A. L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25039 EAST CLARK LAKE ROAD
NISSWA MN
56468
US

IV. Provider business mailing address

PO BOX 777
NISSWA MN
56468-0777
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-2657
  • Fax: 218-963-4692
Mailing address:
  • Phone: 218-963-2657
  • Fax: 218-963-4692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP0386
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: