Provider Demographics
NPI:1588014054
Name:DOCKENDORF, MARA ROSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:ROSE
Last Name:DOCKENDORF
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:ROSE
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:310 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3218
Mailing Address - Country:US
Mailing Address - Phone:612-223-8898
Mailing Address - Fax:612-223-8899
Practice Address - Street 1:310 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3218
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:612-223-8899
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01251101YP2500X
MNLP6445103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional