Provider Demographics
NPI:1497019475
Name:HOOGS, MARIETTA MUME (PHD, LP, ABPP)
Entity Type:Individual
Prefix:DR
First Name:MARIETTA
Middle Name:MUME
Last Name:HOOGS
Suffix:
Gender:F
Credentials:PHD, LP, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E NICOLLET BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6772
Mailing Address - Country:US
Mailing Address - Phone:952-435-8516
Mailing Address - Fax:
Practice Address - Street 1:501 E NICOLLET BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6772
Practice Address - Country:US
Practice Address - Phone:952-435-8516
Practice Address - Fax:763-302-4336
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008806103T00000X
MNLP5639103G00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1497019475Medicaid