Provider Demographics
NPI:1962590513
Name:TALLAKSON, RUTH (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:RUTH
Middle Name:
Last Name:TALLAKSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 SNELLING AVE N
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6753
Mailing Address - Country:US
Mailing Address - Phone:651-647-1001
Mailing Address - Fax:651-647-6111
Practice Address - Street 1:91 SNELLING AVE N
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6753
Practice Address - Country:US
Practice Address - Phone:651-647-1001
Practice Address - Fax:651-647-6111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0208103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN25094OtherAMERICA'S PPO
MN6H601TAOtherBLUE CROSS BLUE SHIELD