Provider Demographics
NPI:1265802532
Name:STILLWATER PSYCHOLOGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:STILLWATER PSYCHOLOGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-356-4436
Mailing Address - Street 1:1611 COUNTY ROAD B W STE 102
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4053
Mailing Address - Country:US
Mailing Address - Phone:651-356-4436
Mailing Address - Fax:651-348-8349
Practice Address - Street 1:1611 COUNTY ROAD B W STE 102
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:651-356-4436
Practice Address - Fax:651-348-8349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARTNERS IN RECOVERY, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty