Provider Demographics
NPI:1083863245
Name:MANKATO MENTAL HEALTH ASSOCIATES, PA
Entity Type:Organization
Organization Name:MANKATO MENTAL HEALTH ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:507-345-4448
Mailing Address - Street 1:209 S BROAD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3681
Mailing Address - Country:US
Mailing Address - Phone:507-345-4448
Mailing Address - Fax:507-625-1000
Practice Address - Street 1:209 S BROAD ST
Practice Address - Street 2:SUITE C
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3681
Practice Address - Country:US
Practice Address - Phone:507-345-4448
Practice Address - Fax:507-625-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3697251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN602022400Medicaid