Provider Demographics
NPI:1003195942
Name:PLYMOUTH PSYCH GROUP, LLC
Entity Type:Organization
Organization Name:PLYMOUTH PSYCH GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOKEYE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-271-9005
Mailing Address - Street 1:3021 HARBOR LN N
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5109
Mailing Address - Country:US
Mailing Address - Phone:651-271-9005
Mailing Address - Fax:763-271-2707
Practice Address - Street 1:3021 HARBOR LN N
Practice Address - Street 2:SUITE 206
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5109
Practice Address - Country:US
Practice Address - Phone:651-271-9005
Practice Address - Fax:763-271-2707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty