Healthcare Provider Details

I. General information

NPI: 1053066902
Provider Name (Legal Business Name): ADVANCED PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 BELLE AVE
MANKATO MN
56001-5250
US

IV. Provider business mailing address

304 BELLE AVE
MANKATO MN
56001-5250
US

V. Phone/Fax

Practice location:
  • Phone: 877-909-5511
  • Fax: 507-888-0001
Mailing address:
  • Phone: 877-909-5511
  • Fax: 507-888-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KESHA FETTIG
Title or Position: CLINIC COORDINATOR
Credential:
Phone: 507-735-6449