Provider Demographics
NPI:1497776736
Name:PREUSSLER, REBECCA SUZANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNE
Last Name:PREUSSLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1929
Mailing Address - Country:US
Mailing Address - Phone:701-234-4141
Mailing Address - Fax:701-234-4160
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-4141
Practice Address - Fax:701-234-4160
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004394103TP0814X
ND378103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13393Medicaid
MN365471100Medicaid
MN365471100Medicaid
Q39961Medicare UPIN
NDN25408Medicare PIN