Provider Demographics
NPI:1972727105
Name:SUBURBAN NORTH PSYCHOLOGICAL SERVICES, P.A.
Entity type:Organization
Organization Name:SUBURBAN NORTH PSYCHOLOGICAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FERDE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FRITSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:651-647-1653
Mailing Address - Street 1:1512 CALIFORNIA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2105
Mailing Address - Country:US
Mailing Address - Phone:651-647-1653
Mailing Address - Fax:612-379-3183
Practice Address - Street 1:1313 5TH ST SE
Practice Address - Street 2:MAILBOX 45, SUITE 114 B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4504
Practice Address - Country:US
Practice Address - Phone:612-819-7485
Practice Address - Fax:612-379-3183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2514103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNFW8566Medicare ID - Type Unspecified