Provider Demographics
NPI:1508966730
Name:ORSAK, CHARLES (LP, PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ORSAK
Suffix:
Gender:M
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 1:400 EAST 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-766-8364
Mailing Address - Fax:
Practice Address - Street 1:510 W QUINCE ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3338
Practice Address - Country:US
Practice Address - Phone:218-724-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN718213900Medicaid
MN718213900Medicaid