Provider Demographics
NPI:1780992479
Name:MICHAEL V. DESANCTIS, PHD, ABPP, LICENSED PSYCHOLOGIST PLLC
Entity type:Organization
Organization Name:MICHAEL V. DESANCTIS, PHD, ABPP, LICENSED PSYCHOLOGIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VITO
Authorized Official - Last Name:DESANCTIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-225-9222
Mailing Address - Street 1:413 WACOUTA ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1645
Mailing Address - Country:US
Mailing Address - Phone:651-225-9222
Mailing Address - Fax:651-225-9224
Practice Address - Street 1:413 WACOUTA ST STE 550
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1645
Practice Address - Country:US
Practice Address - Phone:651-225-9222
Practice Address - Fax:651-225-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-16
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1395103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN261348400OtherMINNESOTA HEALTH CARE