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General NPI Number Information
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NPI Number | 1801182837
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Entity Type | Organization
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Legal Business Name | MARY MULLENBACH, PHD, LP, INC
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Dates
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Enumeration Date | 06/28/2011
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Last Update Date | 08/23/2018
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Provider Practice Location Address
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Address Line | 6550 YORK AVE. S. SUITE 503
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City | EDINA
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State | MN
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Zip | 55435
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Country | US
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Telephone | 612-801-3316
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Fax |
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Provider Business Mailing Address
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Address Line | 6550 YORK AVE. S. SUITE 503
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City | EDINA
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State | MN
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Zip | 55435-2336
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY MULLENBACH
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Credential | PH.D., L.P.
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Telephone | 612-801-3316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 4360
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License Number State | MN
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