Provider Demographics
NPI:1568425908
Name:THELEN, MARK R (PSYD LP LMFT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:THELEN
Suffix:
Gender:M
Credentials:PSYD LP LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-0102
Mailing Address - Country:US
Mailing Address - Phone:763-370-0243
Mailing Address - Fax:
Practice Address - Street 1:261 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-9317
Practice Address - Country:US
Practice Address - Phone:763-370-0243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN645106H00000X
MNLP2992103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6118960OtherUBH
105008OtherUCARE
HP27417OtherHEALTH PARTNERS
MN1023459OtherPREFERRED ONE
680007902OtherRR MEDICARE
MN704817300Medicaid
7H446THOtherBCBS
7H446THOtherBCBS