Provider Demographics
NPI:1700972122
Name:AGASSIZ ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:AGASSIZ ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-746-6336
Mailing Address - Street 1:2424 32ND AVE S
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6545
Mailing Address - Country:US
Mailing Address - Phone:701-746-6336
Mailing Address - Fax:701-772-1030
Practice Address - Street 1:2424 32ND AVE S
Practice Address - Street 2:STE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6545
Practice Address - Country:US
Practice Address - Phone:701-746-6336
Practice Address - Fax:701-772-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457916Medicaid
MN309K4AGOtherBLUECROSSBLUESHIELD OF MN
ND1457916Medicaid