Healthcare Provider Details

I. General information

NPI: 1427299023
Provider Name (Legal Business Name): SUSAN DE VRIES MA, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 ASBURY ST SUITE 310
SAINT PAUL MN
55104-1849
US

IV. Provider business mailing address

570 ASBURY ST SUITE 310
SAINT PAUL MN
55104-1849
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-7010
  • Fax: 651-646-7668
Mailing address:
  • Phone: 651-646-7010
  • Fax: 651-646-7668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLP 1035
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: