1447301908 NPI number — DR. MARY G FREITAG PSYD LP

Table of content: DR. MARY G FREITAG PSYD LP (NPI 1447301908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447301908 NPI number — DR. MARY G FREITAG PSYD LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREITAG
Provider First Name:
MARY
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD LP
Provider Gender Code:
F

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:
1447301908
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10480 PERKINS AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082-9273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-357-3216
Provider Business Mailing Address Fax Number:
651-730-6657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10480 PERKINS AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55082-9273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-357-3216
Provider Business Practice Location Address Fax Number:
651-730-6657
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP4319 , 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: 014959400 . This is a "MEDICAL ASSISTANCE MHCP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 130952 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0492456 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20358-02 . This is a "BHP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 028H0HA . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6151196 . This is a "UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 028H1FR . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1028022 . This is a "MENTAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP 33776 . This is a "MENTAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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