Healthcare Provider Details

I. General information

NPI: 1548465883
Provider Name (Legal Business Name): INTEGRATIVE PSYCHOLOGICAL SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10480 PERKINS AVE N
STILLWATER MN
55082-9273
US

IV. Provider business mailing address

10480 PERKINS AVE N
STILLWATER MN
55082-9273
US

V. Phone/Fax

Practice location:
  • Phone: 651-357-3216
  • Fax: 651-430-8085
Mailing address:
  • Phone: 651-357-3216
  • Fax: 651-430-8085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4319
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY GENEVIEVE FREITAG
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D., L.P.
Phone: 651-357-3216