Provider Demographics
NPI:1477628477
Name:HAMMARGREN, MARY (MA, LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HAMMARGREN
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 1:625 BROADWAY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1664
Mailing Address - Country:US
Mailing Address - Phone:320-763-4100
Mailing Address - Fax:320-763-4100
Practice Address - Street 1:625 BROADWAY ST STE 105
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1664
Practice Address - Country:US
Practice Address - Phone:320-763-4100
Practice Address - Fax:320-763-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
15Q68HAOtherBCBS OF MN
MN1100530Medicaid