Provider Demographics
NPI:1457446882
Name:LINNIHAN, MARY ELLEN (MA, LP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:LINNIHAN
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 POKEGAMA AVENUE SOUTH
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-244-9414
Mailing Address - Fax:
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3800
Practice Address - Country:US
Practice Address - Phone:218-244-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3192103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460844500Medicaid
MN9H399LIOtherBCBS PROVIDER #