Basic Information
| Provider Information | |||||||||
| NPI: | 1518256494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARVIN | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | HERFURTH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PSY.D, L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 11010 PRAIRIE LAKES DR | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527462522 | ||||||||
| FaxNumber: | 9527460887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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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 | 103TC0700X | 5322 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.