Provider Demographics
NPI:1124244785
Name:ECKHARDT, MARIAN (PSYD, LP)
Entity type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:
Last Name:ECKHARDT
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:MS
Other - First Name:MARIAN
Other - Middle Name:
Other - Last Name:TESKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8025 34TH PL N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1926
Mailing Address - Country:US
Mailing Address - Phone:612-393-7885
Mailing Address - Fax:763-546-8577
Practice Address - Street 1:8025 34TH PL N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55427-1926
Practice Address - Country:US
Practice Address - Phone:612-393-7885
Practice Address - Fax:763-546-8577
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MNLP5175103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1124244785Medicaid
680002860OtherMEDICARE PTAN