Provider Demographics
NPI:1689120123
Name:SHOSHANA CENTER FOR REPRODUCTIVE HEALTH PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:SHOSHANA CENTER FOR REPRODUCTIVE HEALTH PSYCHOLOGY, PLLC
Other - Org Name:SHOSHANA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP, CPLC
Authorized Official - Phone:651-645-5504
Mailing Address - Street 1:1836 IGLEHART AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3522
Mailing Address - Country:US
Mailing Address - Phone:651-431-8506
Mailing Address - Fax:651-603-8528
Practice Address - Street 1:475 CLEVELAND AVE N
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5031
Practice Address - Country:US
Practice Address - Phone:651-645-5504
Practice Address - Fax:651-645-5517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1281103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty