Provider Demographics
NPI:1457344731
Name:FARIBAULT PSYCHOLOGICAL SERVICES PA
Entity Type:Organization
Organization Name:FARIBAULT PSYCHOLOGICAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LP
Authorized Official - Phone:507-334-6518
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-0901
Mailing Address - Country:US
Mailing Address - Phone:507-334-6518
Mailing Address - Fax:507-333-2307
Practice Address - Street 1:329 FARIBAULT RD
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5780
Practice Address - Country:US
Practice Address - Phone:507-334-6518
Practice Address - Fax:507-333-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN34146HOOtherBLUE CROSS BLUE SHIELD
D179OtherSOUTH COUNTRY HEALTH CARE
97491OtherPREFERRED ONE
D179OtherU CARE
15534OtherHEALTH PARTNERS
97491OtherPREFERRED ONE