Provider Demographics
NPI:1669464905
Name:PRICHARD, JOHN MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:PRICHARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 MCANDREWS RD W
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4432
Mailing Address - Country:US
Mailing Address - Phone:952-808-3166
Mailing Address - Fax:952-892-1722
Practice Address - Street 1:1500 MCANDREWS RD W
Practice Address - Street 2:SUITE 209
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4432
Practice Address - Country:US
Practice Address - Phone:952-808-3166
Practice Address - Fax:952-892-1722
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0623103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN283551700Medicaid
MN6133246OtherMEDICA PROVIDER NUMBER
MN9L867PROtherBLUECROSS BLUESHIELD
MN283551700Medicaid