Basic Information
Provider Information
NPI: 1689129546
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TRUSCOTT
FirstName: MARY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LMFT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 927 TRETTEL LN
Address2:  
City: CLOQUET
State: MN
PostalCode: 557201345
CountryCode: US
TelephoneNumber: 2188791227
FaxNumber:  
Practice Location
Address1: 2232 2ND AVE E STE 5
Address2:  
City: INTERNATIONAL FALLS
State: MN
PostalCode: 566494042
CountryCode: US
TelephoneNumber: 2183197171
FaxNumber: 1822604749
Other Information
ProviderEnumerationDate: 08/22/2016
LastUpdateDate: 01/21/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/21/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X3298MNY Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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