Provider Demographics
NPI:1033264734
Name:PERLINGER, MARY BETH (LP)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:PERLINGER
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 UNIVERSITY AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3325
Mailing Address - Country:US
Mailing Address - Phone:612-861-1688
Mailing Address - Fax:612-728-5301
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-861-1688
Practice Address - Fax:612-728-5301
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4060101YM0800X
MN5767103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN996743500Medicaid