Provider Demographics
NPI:1235351826
Name:MULLENBACH, MARY (PHD, LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MULLENBACH
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 YORK AVE. S.
Mailing Address - Street 2:SUITE 503
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2336
Mailing Address - Country:US
Mailing Address - Phone:952-426-3034
Mailing Address - Fax:612-540-0460
Practice Address - Street 1:6550 YORK AVE. S.
Practice Address - Street 2:SUITE 503
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-426-3034
Practice Address - Fax:612-540-0460
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4360103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1235351826Medicaid
MN301R4MUOtherBLUE CROSS PROVIDER
MNLP 4360MNOtherLICENCED PSYCHOLOGIST
MN616160100Medicaid