Provider Demographics
NPI:1508504192
Name:PSYCHODYNAMIC THERAPY
Entity Type:Organization
Organization Name:PSYCHODYNAMIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUBANOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-254-4789
Mailing Address - Street 1:3610 S WESTERN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6143
Mailing Address - Country:US
Mailing Address - Phone:605-254-4789
Mailing Address - Fax:
Practice Address - Street 1:3610 S WESTERN AVE STE 2
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6143
Practice Address - Country:US
Practice Address - Phone:605-254-4789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty