Provider Demographics
NPI:1467597567
Name:REISETTER, TRESSA KAY (PHD, LP, NCSP)
Entity Type:Individual
Prefix:
First Name:TRESSA
Middle Name:KAY
Last Name:REISETTER
Suffix:
Gender:F
Credentials:PHD, LP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9585
Mailing Address - Country:US
Mailing Address - Phone:612-597-2737
Mailing Address - Fax:763-566-2944
Practice Address - Street 1:621 RED OAK DR
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-9585
Practice Address - Country:US
Practice Address - Phone:612-597-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019014342103TC0700X
MNLP4752103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14450911OtherCAQH