Healthcare Provider Details

I. General information

NPI: 1184189714
Provider Name (Legal Business Name): SUCCESS PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 CARTER AVE # 202
SAINT PAUL MN
55108-1638
US

IV. Provider business mailing address

2239 CARTER AVE # 202
SAINT PAUL MN
55108-1638
US

V. Phone/Fax

Practice location:
  • Phone: 612-965-6135
  • Fax: 651-645-2439
Mailing address:
  • Phone: 612-965-6135
  • Fax: 651-645-2439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN PHILLIP HIRSCH
Title or Position: CEO
Credential: PH.D.
Phone: 612-965-6135