Healthcare Provider Details

I. General information

NPI: 1689120123
Provider Name (Legal Business Name): SHOSHANA CENTER FOR REPRODUCTIVE HEALTH PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 CLEVELAND AVE N SUITE 200
SAINT PAUL MN
55104-5031
US

IV. Provider business mailing address

1836 IGLEHART AVE
SAINT PAUL MN
55104-3522
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5504
  • Fax: 651-645-5517
Mailing address:
  • Phone: 651-431-8506
  • Fax: 651-603-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberLP1281
License Number StateMN

VIII. Authorized Official

Name: DR. DEBORAH ELLEN RICH
Title or Position: OWNER/DIRECTOR
Credential: PHD, LP, CPLC
Phone: 651-645-5504