Provider Demographics
NPI:1942372081
Name:MAYOTTE, DONNA RAE (LP)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:RAE
Last Name:MAYOTTE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3713
Mailing Address - Country:US
Mailing Address - Phone:612-879-5293
Mailing Address - Fax:612-879-5272
Practice Address - Street 1:2414 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3713
Practice Address - Country:US
Practice Address - Phone:612-879-5293
Practice Address - Fax:612-879-5272
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61350900Medicaid