Provider Demographics
NPI:1679610265
Name:URSU, MARY WILLIS (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:WILLIS
Last Name:URSU
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 W LAKE OF THE ISLES PKWY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2332
Mailing Address - Country:US
Mailing Address - Phone:612-377-1860
Mailing Address - Fax:
Practice Address - Street 1:2508 W LAKE OF THE ISLES PKWY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2332
Practice Address - Country:US
Practice Address - Phone:612-377-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist