Provider Demographics
NPI:1578697173
Name:MUELLER THEISEN, MARCI MARIE (PSYD, CPRP, LP)
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:MARIE
Last Name:MUELLER THEISEN
Suffix:
Gender:F
Credentials:PSYD, CPRP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11280 86TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4510
Mailing Address - Country:US
Mailing Address - Phone:763-400-7828
Mailing Address - Fax:763-400-7444
Practice Address - Street 1:11280 86TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4510
Practice Address - Country:US
Practice Address - Phone:763-400-7828
Practice Address - Fax:763-400-7444
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328687800Medicaid
MNH400137396OtherMEDICARE PTAN
MN328687800Medicaid