Provider Demographics
NPI:1053066902
Name:ADVANCED PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:ADVANCED PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:ADVANCED PSYCHOLOGICAL SERVICES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-735-6449
Mailing Address - Street 1:304 BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5250
Mailing Address - Country:US
Mailing Address - Phone:877-909-5511
Mailing Address - Fax:507-888-0001
Practice Address - Street 1:304 BELLE AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5250
Practice Address - Country:US
Practice Address - Phone:877-909-5511
Practice Address - Fax:507-888-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty