Provider Demographics
NPI:1598099350
Name:WATER STREET PSYCHOLOGY
Entity Type:Organization
Organization Name:WATER STREET PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:OLCHEFSKE
Authorized Official - Suffix:
Authorized Official - Credentials:LP
Authorized Official - Phone:507-377-1719
Mailing Address - Street 1:668 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-4301
Mailing Address - Country:US
Mailing Address - Phone:507-377-1719
Mailing Address - Fax:507-377-1724
Practice Address - Street 1:668 MEADOW LN
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-4301
Practice Address - Country:US
Practice Address - Phone:507-377-1719
Practice Address - Fax:507-377-1724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5063251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health