Basic Information
| Provider Information | |||||||||
| NPI: | 1649202755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTISON-WYNN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PSY D LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 NORTHDALE BLVD NW STE 220 | ||||||||
| Address2: | |||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635376000 | ||||||||
| FaxNumber: | 7635376666 | ||||||||
| Practice Location | |||||||||
| Address1: | 9550 UPLAND LN N STE 120 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635376000 | ||||||||
| FaxNumber: | 7635376666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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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 | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 4961 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | LP4961 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | P426 | 05 | SD | MEDICAID |