| Great River Psychotherapy Pllc | |
|
790 Cleveland Ave S Ste 201 Saint Paul MN 55116-3845 | |
| (651) 503-7391 | |
| Not Available |
| Full Name | Great River Psychotherapy Pllc |
|---|---|
| Speciality | Psychologist |
| Location | 790 Cleveland Ave S Ste 201, Saint Paul, Minnesota |
| Authorized Official Name and Position | Lisa Paige Rogers (CO-OWNER) |
| Authorized Official Contact | 6515037391 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Great River Psychotherapy Pllc 790 Cleveland Ave S Ste 201 Saint Paul MN 55116-3845 Ph: (651) 503-7391 | Great River Psychotherapy Pllc 790 Cleveland Ave S Ste 201 Saint Paul MN 55116-3845 Ph: (651) 503-7391 |
| NPI Number | 1588206940 |
|---|---|
| Provider Enumeration Date | 10/16/2019 |
| Last Update Date | 04/08/2020 |
| Certification Date | 04/08/2020 |
| Medicare PECOS PAC ID | 5496189268 |
|---|---|
| Medicare Enrollment ID | O20200102002601 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588206940 | NPI | - | NPPES |
| 680003000 | Medicaid | MN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | (* (Not Available)) | Secondary |
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | Lisa P Rogers |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1285706507 PECOS PAC ID: 4880633387 Enrollment ID: I20050425000974 |
| Provider Name | Diane M Rubright |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1942518873 PECOS PAC ID: 5799973210 Enrollment ID: I20160519000892 |
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