Provider Demographics
NPI:1629183173
Name:FARSETH, GEORGANNE (PH D LP)
Entity Type:Individual
Prefix:
First Name:GEORGANNE
Middle Name:
Last Name:FARSETH
Suffix:
Gender:F
Credentials:PH D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 ASBURY ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1849
Mailing Address - Country:US
Mailing Address - Phone:651-646-7010
Mailing Address - Fax:651-646-7668
Practice Address - Street 1:570 ASBURY ST
Practice Address - Street 2:SUITE 310
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1849
Practice Address - Country:US
Practice Address - Phone:651-646-7010
Practice Address - Fax:651-646-7668
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1644103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist