Provider Demographics
NPI:1356466924
Name:GOOSSENS, PAUL J (MA,LP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:GOOSSENS
Suffix:
Gender:M
Credentials:MA,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W SUPERIOR ST
Mailing Address - Street 2:702
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1805
Mailing Address - Country:US
Mailing Address - Phone:218-722-4058
Mailing Address - Fax:218-722-5059
Practice Address - Street 1:314 W SUPERIOR ST
Practice Address - Street 2:702
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1805
Practice Address - Country:US
Practice Address - Phone:218-722-4058
Practice Address - Fax:218-722-5059
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2592103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1006856OtherBHP
MN385R7HAOtherBLUE CROSSBLUE SHIELD
MN466646OtherVALUE OPTIONS
MN6240177OtherMEDICA
MN110228OtherU-CARE