Provider Demographics
NPI:1700944675
Name:LASALLE, GERARD DAVID (MS LP)
Entity type:Individual
Prefix:MR
First Name:GERARD
Middle Name:DAVID
Last Name:LASALLE
Suffix:
Gender:M
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7486 157TH ST W
Mailing Address - Street 2:#103
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124
Mailing Address - Country:US
Mailing Address - Phone:507-581-1800
Mailing Address - Fax:
Practice Address - Street 1:17305 CEDAR AVE SOUTH
Practice Address - Street 2:SUITE 230
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-435-4144
Practice Address - Fax:952-435-4149
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1359103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN826T5LAOtherBCBS
MN11047315OtherPREFERRED ONE