Basic Information
Provider Information
NPI: 1497835656
EntityType: 2
ReplacementNPI:  
OrganizationName: MENTAL HEALTH SYSTEMS PC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103T00000X  Y193400000X SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologist 

ID Information
IDTypeStateIssuerDescription
5806820005MN MEDICAID
844830301 MEDICAOTHER
10395301 UCAREOTHER
103430101 PREFERRED ONEOTHER
9201201 HEALTH PARTNERSOTHER
124R9ME01 BCBSOTHER


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