Provider Demographics
NPI:1427149079
Name:SUPER, ELIZABETH BARAGA (PHD LP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BARAGA
Last Name:SUPER
Suffix:
Gender:F
Credentials:PHD LP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SUPER
Other - Last Name:BARAGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 N 33RD AVE
Mailing Address - Street 2:103
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:325 N 33RD AVE
Practice Address - Street 2:103
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:320-252-2567
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0453103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN417047400Medicaid
MN417047400Medicaid