Provider Demographics
NPI:1801182837
Name:MARY MULLENBACH, PHD, LP, INC
Entity Type:Organization
Organization Name:MARY MULLENBACH, PHD, LP, INC
Other - Org Name:LEGACY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:612-801-3316
Mailing Address - Street 1:6550 YORK AVE. S.
Mailing Address - Street 2:SUITE 503
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6550 YORK AVE. S.
Practice Address - Street 2:SUITE 503
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:612-801-3316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4360103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1801192937Medicaid