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General NPI Number Information
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NPI Number | 1245975010
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Entity Type | Organization
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Legal Business Name | PORTAGE PSYCHOLOGY PA
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Dates
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Enumeration Date | 05/04/2022
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Last Update Date | 05/04/2022
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Provider Practice Location Address
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Address Line | 10125 CROSSTOWN CIR STE 110
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3316
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Country | US
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Telephone | 612-688-5933
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Fax | 612-500-4607
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Provider Business Mailing Address
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Address Line | 10125 CROSSTOWN CIR STE 110
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-3316
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Country | US
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Telephone | 612-688-5933
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Fax | 612-500-4607
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | DR. ANNA KRULL
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Credential | PSYD, LP
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Telephone | 612-986-3333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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