Provider Demographics
NPI:1609891639
Name:VANREKEN, MARY K (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:K
Last Name:VANREKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 METRO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1509
Mailing Address - Country:US
Mailing Address - Phone:952-854-4116
Mailing Address - Fax:952-854-4199
Practice Address - Street 1:7800 METRO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1509
Practice Address - Country:US
Practice Address - Phone:952-854-4116
Practice Address - Fax:952-854-4199
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3060103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM142661OtherUCARE-MN
MN64G50VAOtherBCBSMN
MN337731OtherVALUE OPTIONS
FM61-52099OtherUBH
MN7201179OtherAETNA
FM61-52099OtherUBH