Provider Demographics
NPI:1124043088
Name:MENGERSHAUSEN, KAROLYN DILLER (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:KAROLYN
Middle Name:DILLER
Last Name:MENGERSHAUSEN
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:KAROLYN
Other - Middle Name:D
Other - Last Name:DILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:760 SOUTHCROSS DRIVE WEST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306
Mailing Address - Country:US
Mailing Address - Phone:952-835-5088
Mailing Address - Fax:952-835-5088
Practice Address - Street 1:760 SOUTHCROSS DRIVE WEST
Practice Address - Street 2:SUITE 103
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306
Practice Address - Country:US
Practice Address - Phone:952-835-5088
Practice Address - Fax:952-835-5088
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1219106H00000X
ORC1147101YP2500X
ORT0395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN976487900Medicaid