Provider Demographics
NPI:1649324427
Name:HALL, MARDEE ROSEN (MA, LP)
Entity type:Individual
Prefix:
First Name:MARDEE
Middle Name:ROSEN
Last Name:HALL
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 1:112 W EAGLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6148
Mailing Address - Country:US
Mailing Address - Phone:763-493-3700
Mailing Address - Fax:
Practice Address - Street 1:8401 WAYZATA BLVD
Practice Address - Street 2:SUITE 370
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1343
Practice Address - Country:US
Practice Address - Phone:763-544-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3953103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist