Provider Demographics
NPI:1194937623
Name:MERRIAM PARK PSYCHOLOGICAL SERVICES, PA
Entity type:Organization
Organization Name:MERRIAM PARK PSYCHOLOGICAL SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAULE-KRONMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-647-5722
Mailing Address - Street 1:1678 SELBY AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-647-5722
Mailing Address - Fax:651-647-5723
Practice Address - Street 1:1678 SELBY AVENUE
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-647-5722
Practice Address - Fax:651-647-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN826823100OtherMEDICAL ASSISTANCE
MN01H82MAOtherBCBS GROUP PROVIDER #
MN01H83MAOtherBCBS IND. PROVIDER #
MN107019OtherUCARE
MN6126079OtherUBH
MN1016735OtherPREFERRED ONE
MN6126079OtherMEDICA
MN01H82MAOtherBCBS GROUP PROVIDER #