Provider Demographics
NPI:1194827030
Name:MAST, MARILYN JOY FISKE (MS COUNSELING)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:JOY FISKE
Last Name:MAST
Suffix:
Gender:F
Credentials:MS COUNSELING
Other - Prefix:MISS
Other - First Name:MARILYN
Other - Middle Name:JOY
Other - Last Name:FISKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS COUNSELING
Mailing Address - Street 1:900 LONG LAKE ROAD
Mailing Address - Street 2:SUITE 320 ARDENWOODS PSYCHOLOGICAL SERVICES
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:651-482-9361
Mailing Address - Fax:651-482-9888
Practice Address - Street 1:900 LONG LAKE RD
Practice Address - Street 2:SUITE 320 ARDEN WOODS PSYCHOLOGICAL SERVICES
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6428
Practice Address - Country:US
Practice Address - Phone:651-482-9361
Practice Address - Fax:651-482-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN397106H00000X
MN6615104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist