Provider Demographics
NPI:1609095629
Name:CHILD PSYCHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:CHILD PSYCHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:SULLIVAN
Authorized Official - Last Name:EHLERT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:612-284-1557
Mailing Address - Street 1:12940 HARRIET AVE S
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2680
Mailing Address - Country:US
Mailing Address - Phone:612-284-1557
Mailing Address - Fax:952-432-3826
Practice Address - Street 1:12940 HARRIET AVE S
Practice Address - Street 2:SUITE 250
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2680
Practice Address - Country:US
Practice Address - Phone:612-284-1557
Practice Address - Fax:952-432-3826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5415251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN66G85CHOtherBLUE CROSS BUSINESS
MN218191033686OtherPREFERRED ONE