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General NPI Number Information
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NPI Number | 1447524285
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Entity Type | Organization
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Legal Business Name | FIRESIDE COUNSELING LLC
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Dates
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Enumeration Date | 02/24/2012
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Last Update Date | 01/27/2026
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Provider Practice Location Address
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Address Line | 9352 OAK AVE
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City | WACONIA
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State | MN
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Zip | 55387-9422
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Country | US
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Telephone | 952-373-1279
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Fax | 844-762-3234
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Provider Business Mailing Address
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Address Line | 9352 OAK AVE
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City | WACONIA
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State | MN
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Zip | 55387-9422
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Country | US
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Telephone | 952-270-2086
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Fax |
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Authorized Official
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Title or Position | OWNER, LICENSED PSYCHOLOGIST
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Name | GARY JOSEPH FREITAS
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Credential | PHD
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Telephone | 952-373-1279
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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 | LP 4675
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License Number State | MN
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