Basic Information
| Provider Information | |||||||||
| NPI: | 1336102763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIEBARTH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PMHCNS-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP2295 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 363L00000X | R0820659 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1011796 | 01 | MN | PREFERRED ONE | OTHER | HP25418 | 01 | MN | HEALTH PARTNERS | OTHER | 641K1ZI | 01 | MN | BCBS | OTHER | 816750801 | 05 | MN | MEDICAID | 8363352 | 01 | UBH | OTHER | 990991011796 | 01 | MN | PREFERRED ONE | OTHER | 208M0Z1 | 01 | MN | BCBS | OTHER | 6267250 | 01 | MN | UBH | OTHER | 890001087 | 01 | RR MEDICARE | OTHER | 167750 | 01 | BHP UCARE | OTHER |