Provider Demographics
NPI:1639743768
Name:BIRKELO, MARILYN J
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:BIRKELO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:BIRKELO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7009 WASHBURN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2858
Mailing Address - Country:US
Mailing Address - Phone:612-816-4048
Mailing Address - Fax:
Practice Address - Street 1:1801 AMERICAN BLVD E STE 8
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1230
Practice Address - Country:US
Practice Address - Phone:952-767-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician