Provider Demographics
NPI:1720747082
Name:SANDIDGE, RITA (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:RITA
Middle Name:
Last Name:SANDIDGE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 HIGHWAY 96 E STE 200
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3619
Mailing Address - Country:US
Mailing Address - Phone:651-233-1382
Mailing Address - Fax:
Practice Address - Street 1:1310 HIGHWAY 96 E STE 200
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3619
Practice Address - Country:US
Practice Address - Phone:651-233-1382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6748103TC0700X
MNLP6746103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical