Provider Demographics
NPI:1972802361
Name:SALLY R BRINZA PHD LP LLC
Entity Type:Organization
Organization Name:SALLY R BRINZA PHD LP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BRINZA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-978-5058
Mailing Address - Street 1:7225 FORESTVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-5501
Mailing Address - Country:US
Mailing Address - Phone:612-978-5058
Mailing Address - Fax:
Practice Address - Street 1:7225 FORESTVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-5501
Practice Address - Country:US
Practice Address - Phone:612-978-5058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2586103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7140533-00OtherMINNESOTA HEALTH CARE PROGRAM MA
MN6420206OtherMINNESOTA CARE