Provider Demographics
NPI:1134490469
Name:MENGE, BERNIE JEROME (MA LMFT)
Entity Type:Individual
Prefix:
First Name:BERNIE
Middle Name:JEROME
Last Name:MENGE
Suffix:
Gender:M
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 S FRONTAGE RD STE 275
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-2655
Mailing Address - Country:US
Mailing Address - Phone:651-319-6484
Mailing Address - Fax:651-925-0442
Practice Address - Street 1:1303 S FRONTAGE RD STE 275
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033
Practice Address - Country:US
Practice Address - Phone:651-319-6484
Practice Address - Fax:651-925-0442
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN3335106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113449046Medicaid
MN1790212926Medicaid