Provider Demographics
NPI:1831587062
Name:SOUDER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SOUDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 HENNEPIN AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2642
Mailing Address - Country:US
Mailing Address - Phone:833-482-5546
Mailing Address - Fax:
Practice Address - Street 1:3137 HENNEPIN AVE STE 105
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2642
Practice Address - Country:US
Practice Address - Phone:833-482-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN868101YP2500X
MN00868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional