Provider Demographics
NPI:1730130758
Name:NOLLER, GAIL ANN (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:ANN
Last Name:NOLLER
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2747
Mailing Address - Country:US
Mailing Address - Phone:763-427-6897
Mailing Address - Fax:
Practice Address - Street 1:199 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 310
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5831
Practice Address - Country:US
Practice Address - Phone:763-785-8111
Practice Address - Fax:763-785-8111
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3194103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4912233-00Medicaid