Provider Demographics
NPI:1164569612
Name:HENDRICKSON, MARY LYNN (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PSYD, LP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11900 WAYZATA BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2031
Mailing Address - Country:US
Mailing Address - Phone:952-546-0700
Mailing Address - Fax:952-546-0700
Practice Address - Street 1:11900 WAYZATA BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2031
Practice Address - Country:US
Practice Address - Phone:952-546-0700
Practice Address - Fax:952-546-0700
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7H354HEMedicare UPIN