Basic Information
Provider Information | |||||||||
NPI: | 1326194010 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAAS | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD LP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARKHURST | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSYD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1125 6TH ST SE | ||||||||
Address2: | PO BOX 787 | ||||||||
City: | WILLMAR | ||||||||
State: | MN | ||||||||
PostalCode: | 562014675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202354613 | ||||||||
FaxNumber: | 3202359384 | ||||||||
Practice Location | |||||||||
Address1: | 1125 6TH ST SE | ||||||||
Address2: |   | ||||||||
City: | WILLMAR | ||||||||
State: | MN | ||||||||
PostalCode: | 562014675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202354613 | ||||||||
FaxNumber: | 3202359384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2007 | ||||||||
LastUpdateDate: | 10/31/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP4776 | MN | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
ID Information
ID | Type | State | Issuer | Description | 049N3PA | 01 |   | BCBS | OTHER | HP78777 | 01 |   | HEALTH PARTNERS | OTHER | 152220 | 01 |   | BHP U CARE | OTHER | 523975100 | 05 | MN |   | MEDICAID |