Healthcare Provider Details

I. General information

NPI: 1780918763
Provider Name (Legal Business Name): MARIA MERCEDES RICCARDI PSY D LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVENUE NORTH ST CLOUD HOSPITAL
ST. CLOUD MN
56303-1900
US

IV. Provider business mailing address

1406 6TH AVENUE NORTH ST CLOUD HOSPITAL
ST CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-656-7115
Mailing address:
  • Phone: 320-251-2700
  • Fax: 320-656-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP5779
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: