MEDICARE: GAIL L RISSE PHD

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
1	103G00000X	Clinical Neuropsychologist	LP1122	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699792606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL L RISSE PHD

Provider Business Mailing Address
First Line	:	2720 FAIRVIEW AVE N STE 100
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-1306
Country	:	US
Telephone Number	:	651-241-5290
Fax Number	:	651-377-8474

Provider Business Practice Location Address
First Line	:	2720 FAIRVIEW AVE N STE 100
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-1306
Country	:	US
Telephone Number	:	651-241-5290
Fax Number	:	651-241-5140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	02/10/2022

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Directions to “ GAIL L RISSE PHD” Practice Location

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