Provider Demographics
NPI:1821241340
Name:PSYCHOLOGICAL HEALTHCARE OF MINNESOTA PA
Entity Type:Organization
Organization Name:PSYCHOLOGICAL HEALTHCARE OF MINNESOTA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:GUTHRIE
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-920-2789
Mailing Address - Street 1:15798 VENTURE LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5729
Mailing Address - Country:US
Mailing Address - Phone:952-920-2789
Mailing Address - Fax:952-746-3890
Practice Address - Street 1:15798 VENTURE LN
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5729
Practice Address - Country:US
Practice Address - Phone:952-920-2789
Practice Address - Fax:952-746-3890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2224103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN651353100Medicaid
41B22PSOtherBLUE CROSS BLUE SHIELD