Provider Demographics
NPI:1245975010
Name:PORTAGE PSYCHOLOGY PA
Entity type:Organization
Organization Name:PORTAGE PSYCHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRULL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-986-3333
Mailing Address - Street 1:10125 CROSSTOWN CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3316
Mailing Address - Country:US
Mailing Address - Phone:612-688-5933
Mailing Address - Fax:612-500-4607
Practice Address - Street 1:10125 CROSSTOWN CIR STE 110
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3316
Practice Address - Country:US
Practice Address - Phone:612-688-5933
Practice Address - Fax:612-500-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty