Provider Demographics
NPI:1154403673
Name:SCHAEFER, MARK (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SCHAEFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8009 34TH AVE SO
Mailing Address - Street 2:SUITE 1490
Mailing Address - City:BLOOMINGTON,
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8009 34TH AVE S
Practice Address - Street 2:SUITE 1490
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1794
Practice Address - Country:US
Practice Address - Phone:952-854-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0637103T00000X
MN191106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN217J1SCOtherBLUE CROSS BLUE SHIELD