Provider Demographics
NPI:1255483491
Name:VAN FOSSEN, MARCY (PHD)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 E 3RD ST
Mailing Address - Street 2:201
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3478
Mailing Address - Country:US
Mailing Address - Phone:507-452-7292
Mailing Address - Fax:507-457-9887
Practice Address - Street 1:66 E 3RD ST
Practice Address - Street 2:201
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3478
Practice Address - Country:US
Practice Address - Phone:507-452-7292
Practice Address - Fax:507-457-9887
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4392103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN975T1VAOtherBCBS-MN
MN135853Medicaid
MN731291045880OtherPREFERRED ONE
MNHP55644OtherHEALTHPARTNERS