MEDICARE: DR. MICHAEL JAMES FERRARESE PHD, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP0140	MN

General Provider Information

NPI Number	:	1093868747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JAMES FERRARESE PHD, LP

Provider Business Mailing Address
First Line	:	4635 NICOLS RD
Second Line	:	SUITE 200
City	:	SAINT PAUL
State	:	MN
Zip	:	55122-3337
Country	:	US
Telephone Number	:	952-431-6862
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 NICOLS RD
Second Line	:	SUITE 200
City	:	SAINT PAUL
State	:	MN
Zip	:	55122-3337
Country	:	US
Telephone Number	:	952-431-6862
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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