Basic Information
| Provider Information | |||||||||
| NPI: | 1396859310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIELDS | ||||||||
| FirstName: | MARSHA | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L. P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | PO BOX 8674 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 MADISON AVE | ||||||||
| Address2: | SUITE 352 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 2028 | AZ | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 4328 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 2514-057 | WI | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 2028 | AZ | N | Behavioral Health & Social Service Providers | Psychologist | 103TC2200X | 4328 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TH0100X | 4328 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TP2701X | 4328 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TR0400X | 4328 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 39147700 | 05 | WI | MEDICAID | 0634280-00 | 05 | MN | MEDICAID |