Provider Demographics
NPI:1790869121
Name:RICE, MAVIS (MA LP)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:RICE
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 REGENCY LANE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344
Mailing Address - Country:US
Mailing Address - Phone:952-736-7136
Mailing Address - Fax:952-903-9257
Practice Address - Street 1:6542 REGENCY LN
Practice Address - Street 2:SUITE 206
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7847
Practice Address - Country:US
Practice Address - Phone:952-736-7136
Practice Address - Fax:952-903-9257
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP4004101YM0800X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-50536OtherMEDICA/UBH
FMHP50743OtherHEALTHPARTNERS
MN386981400Medicaid
MN39Q41BUOtherBCBS GROUP
MN83G85K1OtherBCBS INDIVIDUAL
MN167373OtherU CARE
MN30433-01OtherPREFERREDONE (BPH)