Healthcare Provider Details

I. General information

NPI: 1003195942
Provider Name (Legal Business Name): PLYMOUTH PSYCH GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 HARBOR LN N SUITE 206
PLYMOUTH MN
55447-5109
US

IV. Provider business mailing address

3021 HARBOR LN N SUITE 206
PLYMOUTH MN
55447-5109
US

V. Phone/Fax

Practice location:
  • Phone: 651-271-9005
  • Fax: 763-271-2707
Mailing address:
  • Phone: 651-271-9005
  • Fax: 763-271-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ISRAEL SOKEYE
Title or Position: OWNER
Credential: MD
Phone: 651-271-9005