Provider Demographics
NPI:1124049903
Name:RISTAU, ANASTASIA SULLWOLD (PHD LP)
Entity type:Individual
Prefix:DR
First Name:ANASTASIA
Middle Name:SULLWOLD
Last Name:RISTAU
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:DR
Other - First Name:ANASTASIA
Other - Middle Name:C
Other - Last Name:SULLWOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD LP
Mailing Address - Street 1:9400 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1814
Mailing Address - Country:US
Mailing Address - Phone:763-762-8800
Mailing Address - Fax:763-315-4669
Practice Address - Street 1:111 HUNDERTMARK RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1586
Practice Address - Country:US
Practice Address - Phone:952-903-1350
Practice Address - Fax:952-426-3856
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN949674200Medicaid