Healthcare Provider Details

I. General information

NPI: 1679113591
Provider Name (Legal Business Name): RAKSMEY GROTTE LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

IV. Provider business mailing address

451 LEXINGTON PKWY N
SAINT PAUL MN
55104-4636
US

V. Phone/Fax

Practice location:
  • Phone: 651-280-2310
  • Fax: 651-280-3995
Mailing address:
  • Phone: 651-280-2310
  • Fax: 651-280-3995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6496
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: