Provider Demographics
NPI:1225379381
Name:DETERS, LINDA RAE (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:RAE
Last Name:DETERS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-4385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-4385
Practice Address - Country:US
Practice Address - Phone:612-596-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3096-57103T00000X, 103TC0700X, 103TC2200X
MNLP 5597103T00000X, 103TC0700X
MNLP-5597103TC2200X
MNLP5597103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent