Provider Demographics
NPI:1225525645
Name:ENGEBRETSON, MARK J
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:ENGEBRETSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 LYMAN ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-1147
Mailing Address - Country:US
Mailing Address - Phone:218-428-9652
Mailing Address - Fax:
Practice Address - Street 1:5814 ELINOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-1215
Practice Address - Country:US
Practice Address - Phone:218-428-9652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker