Provider Demographics
NPI:1477859437
Name:SOUTH SUBURBAN PSYCHOLOGICAL & COUNSELING SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTH SUBURBAN PSYCHOLOGICAL & COUNSELING SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FERRARESE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:952-431-6862
Mailing Address - Street 1:4635 NICOLS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3337
Mailing Address - Country:US
Mailing Address - Phone:952-431-6862
Mailing Address - Fax:
Practice Address - Street 1:4635 NICOLS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3337
Practice Address - Country:US
Practice Address - Phone:952-431-6862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty