Provider Demographics
NPI:1588794515
Name:THE INSTITUTE FOR PSYCHOLOGICAL & SEXUAL HEALTH, INC.
Entity type:Organization
Organization Name:THE INSTITUTE FOR PSYCHOLOGICAL & SEXUAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETSOULIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LP
Authorized Official - Phone:218-727-7353
Mailing Address - Street 1:314 W SUPERIOR ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1805
Mailing Address - Country:US
Mailing Address - Phone:218-727-7353
Mailing Address - Fax:218-727-2646
Practice Address - Street 1:314 W SUPERIOR ST
Practice Address - Street 2:SUITE 600
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1805
Practice Address - Country:US
Practice Address - Phone:218-727-7353
Practice Address - Fax:218-727-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3664103T00000X
MN156291041C0700X
MNLP4322103G00000X
MNLP3014103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29A16INOtherBLUE CROSS BLUE SHIELD