Provider Demographics
NPI:1952544934
Name:GREAT RIVER PSYCHOLOGICAL SERVICES, P.A.
Entity Type:Organization
Organization Name:GREAT RIVER PSYCHOLOGICAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD,
Authorized Official - Phone:218-759-1576
Mailing Address - Street 1:403 4TH ST NW
Mailing Address - Street 2:SUITE 245
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3142
Mailing Address - Country:US
Mailing Address - Phone:218-444-6912
Mailing Address - Fax:218-444-6937
Practice Address - Street 1:403 4TH ST NW
Practice Address - Street 2:SUITE 245
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3142
Practice Address - Country:US
Practice Address - Phone:218-444-6912
Practice Address - Fax:218-444-6937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3903103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty