Basic Information
Provider Information | |||||||||
NPI: | 1497835656 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MENTAL HEALTH SYSTEMS PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7200 FRANCE AVE | ||||||||
Address2: | STE 327 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554354310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528352002 | ||||||||
FaxNumber: | 9528359889 | ||||||||
Practice Location | |||||||||
Address1: | 7200 FRANCE AVE | ||||||||
Address2: | STE 327 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554354310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528352002 | ||||||||
FaxNumber: | 9528359889 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARLSON | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | RICHARD | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9528352002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PSYD LP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 58068200 | 05 | MN |   | MEDICAID | 8448303 | 01 |   | MEDICA | OTHER | 103953 | 01 |   | UCARE | OTHER | 1034301 | 01 |   | PREFERRED ONE | OTHER | 92012 | 01 |   | HEALTH PARTNERS | OTHER | 124R9ME | 01 |   | BCBS | OTHER |