Provider Demographics
NPI:1710016043
Name:MACTAGGERT, PATRICIA J (MA,LP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
Last Name:MACTAGGERT
Suffix:
Gender:F
Credentials:MA,LP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:J
Other - Last Name:STERNAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LP
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-0819
Mailing Address - Country:US
Mailing Address - Phone:612-803-2533
Mailing Address - Fax:
Practice Address - Street 1:804 LAKE ST E
Practice Address - Street 2:SUITE 204
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1980
Practice Address - Country:US
Practice Address - Phone:612-803-2533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2278103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN68413STOtherBLUECROSSBLUESHIELD PROVI