Provider Demographics
NPI:1992768451
Name:CONNER, MARY ELIZABETH (MA LP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:CONNER
Suffix:
Gender:F
Credentials:MA LP
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Mailing Address - Street 1:1930 COON RAPIDS BLVD
Mailing Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD
Practice Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2008-12-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3985103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
270052697OtherUBH
HP27005OtherHEALTH PARTNERS
MN813225900Medicaid
MN286M4C0OtherBCBS
MN84G92COOtherBCBS
123202OtherUCARE
MN6250882OtherUBH
MN1024500OtherPREFERRED ONE