Provider Demographics
NPI:1972649846
Name:VERKENNES, MARY KATHERINE (MA LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:VERKENNES
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:PO BOX 777
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-0777
Mailing Address - Country:US
Mailing Address - Phone:218-963-2657
Mailing Address - Fax:218-963-4692
Practice Address - Street 1:25039 EAST CLARK LAKE ROAD
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468
Practice Address - Country:US
Practice Address - Phone:218-963-2657
Practice Address - Fax:218-963-4692
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0386103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11806VEOtherBCBS PROVIDER ID
MN6235127OtherMEDICA AND BHP PROVIDER #
MN126422OtherUCARE PROVIDER ID
MN11806Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID