Provider Demographics
NPI:1750368353
Name:GEWIRTZ, ABIGAIL HADASSAH (PHD, LP)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:HADASSAH
Last Name:GEWIRTZ
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 1:1088 OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118
Mailing Address - Country:US
Mailing Address - Phone:651-365-1249
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE WEST
Practice Address - Street 2:STE 229N
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4278103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN137T0GEOtherBCBS OF MN
MN438230700Medicaid
MN6133092OtherMEDICA