1780992479 NPI number — MICHAEL V. DESANCTIS, PHD, ABPP, LICENSED PSYCHOLOGIST PLLC

Table of content: (NPI 1780992479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780992479 NPI number — MICHAEL V. DESANCTIS, PHD, ABPP, LICENSED PSYCHOLOGIST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL V. DESANCTIS, PHD, ABPP, LICENSED PSYCHOLOGIST PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780992479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 WACOUTA ST STE 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55101-1645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-225-9222
Provider Business Mailing Address Fax Number:
651-225-9224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 WACOUTA ST STE 550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-225-9222
Provider Business Practice Location Address Fax Number:
651-225-9224
Provider Enumeration Date:
09/16/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DESANCTIS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
VITO
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
651-225-9222

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  1395 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 261348400 . This is a "MINNESOTA HEALTH CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".