Provider Demographics
NPI:1184650400
Name:HARBOR CITY PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:HARBOR CITY PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOSSENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-722-4058
Mailing Address - Street 1:324 W SUPERIOR ST STE 730
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1720
Mailing Address - Country:US
Mailing Address - Phone:218-722-4058
Mailing Address - Fax:218-722-4059
Practice Address - Street 1:324 W SUPERIOR ST STE 730
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1720
Practice Address - Country:US
Practice Address - Phone:218-722-4058
Practice Address - Fax:218-722-4059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2592103TC0700X
MNLP4732103TC0700X
MN75601041C0700X
MN64431041C0700X
MN196351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN038158600Medicaid
MNBCBS385R5HAOther2
MNCO3501Medicare PIN