Provider Demographics
NPI:1548610561
Name:PEASE, MARA D (PSYD, LP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:D
Last Name:PEASE
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:D
Other - Last Name:LOCKETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:1600 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3898
Mailing Address - Country:US
Mailing Address - Phone:651-379-5157
Mailing Address - Fax:651-379-5159
Practice Address - Street 1:1600 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 12
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-379-5157
Practice Address - Fax:651-379-5159
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2018-07-30
Deactivation Date:2017-10-02
Deactivation Code:
Reactivation Date:2018-02-20
Provider Licenses
StateLicense IDTaxonomies
MN103T00000X
MNLP6204103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist