Provider Demographics
NPI:1679628192
Name:MANKATO PSYCHOLOGY CLINIC, PLC
Entity Type:Organization
Organization Name:MANKATO PSYCHOLOGY CLINIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGGYSUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:507-387-1350
Mailing Address - Street 1:209 S 2ND ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3626
Mailing Address - Country:US
Mailing Address - Phone:507-387-1350
Mailing Address - Fax:507-387-6605
Practice Address - Street 1:209 S 2ND ST
Practice Address - Street 2:SUITE 306
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3626
Practice Address - Country:US
Practice Address - Phone:507-387-1350
Practice Address - Fax:507-387-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1926616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN81G62MAOtherBLUE CROSS
MN114490OtherUCARE
MN6H521MAOtherBLUE CROSS
MN6H520MAOtherBLUE CROSS
MN155H1MAOtherBLUE CROSS
MN155H1MAOtherBLUE CROSS
MN6H521MAOtherBLUE CROSS