Provider Demographics
NPI:1699892745
Name:NELSON, MARY DOYLE (MA, LP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DOYLE
Last Name:NELSON
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 1:703 OWATONNA ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-2118
Mailing Address - Country:US
Mailing Address - Phone:507-625-4442
Mailing Address - Fax:507-537-0824
Practice Address - Street 1:703 OWATONNA ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-2118
Practice Address - Country:US
Practice Address - Phone:507-625-4442
Practice Address - Fax:507-537-0824
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3743103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN431K6FAMedicare UPIN
MNHP52668Medicare UPIN