Provider Demographics
NPI:1336102763
Name:ZIEBARTH, MARK JAMES (PMHCNS-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:ZIEBARTH
Suffix:
Gender:M
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2295103T00000X
MNR0820659363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1011796OtherPREFERRED ONE
MNHP25418OtherHEALTH PARTNERS
MN641K1ZIOtherBCBS
MN816750801Medicaid
8363352OtherUBH
MN990991011796OtherPREFERRED ONE
MN208M0Z1OtherBCBS
MN6267250OtherUBH
890001087OtherRR MEDICARE
167750OtherBHP UCARE
MN890000317Medicare PIN
MN890000184Medicare ID - Type Unspecified
MN990991011796OtherPREFERRED ONE