Provider Demographics
NPI:1437934890
Name:GORODZINSKY, AYALA (LP, PHD)
Entity Type:Individual
Prefix:
First Name:AYALA
Middle Name:
Last Name:GORODZINSKY
Suffix:
Gender:F
Credentials:LP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 BEDFORD HIGHWAY
Mailing Address - Street 2:2015
Mailing Address - City:BEDFORD
Mailing Address - State:NOVA SCOTIA
Mailing Address - Zip Code:B4A2X9
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6959103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical