1184650400 NPI number — HARBOR CITY PSYCHOLOGICAL ASSOCIATES

Table of content: (NPI 1184650400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184650400 NPI number — HARBOR CITY PSYCHOLOGICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARBOR CITY PSYCHOLOGICAL ASSOCIATES
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:
1184650400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 W SUPERIOR ST STE 730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55802-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-722-4058
Provider Business Mailing Address Fax Number:
218-722-4059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 W SUPERIOR ST STE 730
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-4058
Provider Business Practice Location Address Fax Number:
218-722-4059
Provider Enumeration Date:
06/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOOSSENS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-722-4058

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP2592 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: LP4732 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 7560 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6443 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 19635 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 038158600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: BCBS385R5HA . This is a "2" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".