Provider Demographics
NPI:1548998867
Name:MCMINN, MARLA (MA, PLPC)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:MCMINN
Suffix:
Gender:F
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:
Other - Last Name:MCINGVALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3148 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-7366
Mailing Address - Country:US
Mailing Address - Phone:901-484-4256
Mailing Address - Fax:
Practice Address - Street 1:6858 SWINNEA RD BLDG 7
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9493
Practice Address - Country:US
Practice Address - Phone:662-536-6210
Practice Address - Fax:662-510-8820
Is Sole Proprietor?:No
Enumeration Date:2022-08-13
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
32-0124592OtherAETNA