Healthcare Provider Details

I. General information

NPI: 1588794515
Provider Name (Legal Business Name): THE INSTITUTE FOR PSYCHOLOGICAL & SEXUAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W SUPERIOR ST SUITE 600
DULUTH MN
55802-1805
US

IV. Provider business mailing address

314 W SUPERIOR ST SUITE 600
DULUTH MN
55802-1805
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-7353
  • Fax: 218-727-2646
Mailing address:
  • Phone: 218-727-7353
  • Fax: 218-727-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3664
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15629
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP4322
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3014
License Number StateMN

VIII. Authorized Official

Name: CHRISTOS PETSOULIS
Title or Position: DIRECTOR
Credential: M.A., L.P.
Phone: 218-727-7353