Provider Demographics
NPI:1184988966
Name:SOMERS PSYCHOLOGICAL SERVICES, P.A.
Entity type:Organization
Organization Name:SOMERS PSYCHOLOGICAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SOMERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:763-201-1090
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:763-201-1090
Mailing Address - Fax:763-201-1095
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:763-201-1090
Practice Address - Fax:763-201-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1856251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN913252000Medicaid
MN913252000Medicaid
680001528Medicare PIN