Provider Demographics
NPI:1922151596
Name:PEARSON, MARDELLE BRANDT (MA LP)
Entity Type:Individual
Prefix:
First Name:MARDELLE
Middle Name:BRANDT
Last Name:PEARSON
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2172 MIDLAND VIEW CT N
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-5304
Mailing Address - Country:US
Mailing Address - Phone:612-267-3446
Mailing Address - Fax:
Practice Address - Street 1:2172 MIDLAND VIEW CT N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-5304
Practice Address - Country:US
Practice Address - Phone:612-267-3446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2890103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13434PEOtherBCBS
MN1G086PEOtherBCBS INDIVIDUAL