Provider Demographics
NPI:1548465883
Name:INTEGRATIVE PSYCHOLOGICAL SERVICES, P.A.
Entity type:Organization
Organization Name:INTEGRATIVE PSYCHOLOGICAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GENEVIEVE
Authorized Official - Last Name:FREITAG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:651-357-3216
Mailing Address - Street 1:10480 PERKINS AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-9273
Mailing Address - Country:US
Mailing Address - Phone:651-357-3216
Mailing Address - Fax:651-430-8085
Practice Address - Street 1:10480 PERKINS AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9273
Practice Address - Country:US
Practice Address - Phone:651-357-3216
Practice Address - Fax:651-430-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X
MNLP4319103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN74G37FROtherMENTAL HEALTH
MN028H0HAOtherMENTAL HEALTH
MNHP33776OtherMENTAL HEALTH
MN103T00000XOtherPSYCHOLOGIST
MN130952OtherMENTAL HEALTH
MN0492456Medicaid
MN1028022OtherMENTAL HEALTH
MN1382591OtherMENTAL HEALTH
MN61-57516OtherMENTAL HEALTH