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NPI Code Detail

MEDICARE: SOUTH SUBURBAN PSYCHOLOGICAL & COUNSELING SERVICES, PLLC

MEDICARE: SOUTH SUBURBAN PSYCHOLOGICAL & COUNSELING SERVICES, PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist

General Provider Information

NPI Number : 1477859437
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH SUBURBAN PSYCHOLOGICAL & COUNSELING SERVICES, PLLC
Provider Business Mailing Address
First Line : 4635 NICOLS RD
Second Line : SUITE 200
City : EAGAN
State : MN
Zip : 55122-3337
Country : US
Telephone Number : 952-431-6862
Fax Number :
Provider Business Practice Location Address
First Line : 4635 NICOLS RD
Second Line : SUITE 200
City : EAGAN
State : MN
Zip : 55122-3337
Country : US
Telephone Number : 952-431-6862
Fax Number :
Authorized Official
Title or Position : PSYCHOLOGIST/OWNER
Name : MICHAEL JAMES FERRARESE
Credential : PH.D., L.P.
Telephone Number : 952-431-6862
Provider Enumeration Date : 02/08/2011
Last Update Date : 02/08/2011

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