Active NPI
Mary Lynn Hendrickson, PSY.D., LP
- Clinical Psychologist
- Minnetonka, MN
National Provider Identifier
1164569612
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- LP3184
- Practice address
- 11900 Wayzata Blvd
Suite 216
Minnetonka, MN 55305-2031 - Phone
- (952) 546-0700
- Fax
- (952) 546-0700
- NPI assigned
- Jan 31, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | LP3184 | MN | Primary |
Addresses
Primary practice location
11900 Wayzata Blvd
Suite 216
Minnetonka, MN 55305-2031
Mailing address
11900 Wayzata Blvd
Suite 216
Minnetonka, MN 55305-2031
Phone (952) 546-0700
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Dec 23, 2024 through Dec 23, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP3184 | MN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170201600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1164569612",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11900 WAYZATA BLVD",
"address_2": "SUITE 216",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553052031",
"telephone_number": "952-546-0700",
"fax_number": "952-546-0700"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11900 WAYZATA BLVD",
"address_2": "SUITE 216",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553052031",
"telephone_number": "952-546-0700",
"fax_number": "952-546-0700"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HENDRICKSON",
"first_name": "MARY",
"middle_name": "LYNN",
"credential": "PSY.D., LP",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-01-31",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "LP3184",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minnetonka, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.