Provider Demographics
NPI:1205559416
Name:RAEKER-REBEK, MARY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:RAEKER-REBEK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:RAEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2497 7TH AVE E STE 108
Mailing Address - Street 2:
Mailing Address - City:NORTH ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2949
Mailing Address - Country:US
Mailing Address - Phone:651-769-6437
Mailing Address - Fax:651-769-6599
Practice Address - Street 1:2497 7TH AVE E STE 101
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-2946
Practice Address - Country:US
Practice Address - Phone:651-769-6400
Practice Address - Fax:651-769-6449
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6759103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist