Provider Demographics
NPI:1982689592
Name:LASSEGARD, MARYANNE ANNE (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:MARYANNE
Middle Name:ANNE
Last Name:LASSEGARD
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 INTERLACHEN DR NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4507
Mailing Address - Country:US
Mailing Address - Phone:763-434-6570
Mailing Address - Fax:763-434-6570
Practice Address - Street 1:521 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2016
Practice Address - Country:US
Practice Address - Phone:612-306-4721
Practice Address - Fax:763-434-6570
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2187101YM0800X, 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TF0000X, 103TH0100X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN854806OtherARAZ
FM08S11LUOtherBCBS
MN031016600Medicaid
MN57610OtherCIGNA
FM6124240OtherMEDICA
MN680001481Medicare ID - Type Unspecified