Provider Demographics
NPI:1558414136
Name:BECK, SALLY IRENE (LMFT, PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:IRENE
Last Name:BECK
Suffix:
Gender:F
Credentials:LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1502
Mailing Address - Country:US
Mailing Address - Phone:952-451-3660
Mailing Address - Fax:952-582-1666
Practice Address - Street 1:110 1ST ST E
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1502
Practice Address - Country:US
Practice Address - Phone:952-451-3660
Practice Address - Fax:952-582-1666
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1739106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1558414136Medicaid