NPIMap

Organization Active NPI

Mary Mullenbach, PHD, LP, Inc

Doing business as Legacy Mental Health Center

  • Psychologist
  • Edina, MN
National Provider Identifier
1801182837
Registry record updated Aug 23, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
4360 Issued in MN
Legal business name
MARY MULLENBACH, PHD, LP, INC
Doing business as
Legacy Mental Health Center
Practice address
6550 York Ave. S.
Suite 503
Edina, MN 55435
Phone
(612) 801-3316
NPI assigned
Jun 28, 2011
Last updated
Aug 23, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 23, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Mary Mullenbach, PH.D., L.P.NPI 1235351826
Title
President
Phone
(612) 801-3316

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychologist 103T00000X 4360 MN Primary

Addresses

Primary practice location

6550 York Ave. S.
Suite 503
Edina, MN 55435

Mailing address

6550 York Ave. S.
Suite 503
Edina, MN 55435-2336

Other identifiers 1

IdentifierTypeStateIssuer
1801192937MedicaidMN

Other names 1

  • Legacy Mental Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111212000760 MN Part B Supplier - Clinic/Group Practice 5799950283 Receives reassigned benefits from 23 practitioners
Practice locations: Edina, MN

National Provider Directory

National Provider Directory

Locations

6550 York Ave S
Ste 417
Minneapolis, MN 55435
Phone (952) 426-3034

6550 York Ave S
Ste 503
Minneapolis, MN 55435
Phone (952) 426-3034

Practitioners & affiliated clinicians

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 29

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1309219200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1534982400000",
    "number": "1801182837",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6550 YORK AVE. S.",
            "address_2": "SUITE 503",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6550 YORK AVE. S.",
            "address_2": "SUITE 503",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "55435",
            "telephone_number": "612-801-3316"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARY MULLENBACH, PHD, LP, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-28",
        "last_updated": "2018-08-23",
        "status": "A",
        "authorized_official_last_name": "MULLENBACH",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "612-801-3316",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PH.D., L.P."
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MN",
            "license": "4360",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1801192937",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Legacy Mental Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Edina, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.