Provider Demographics
NPI:1447301908
Name:FREITAG, MARY G (PSYD LP)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:G
Last Name:FREITAG
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
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:651-730-6657
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:651-730-6657
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4319103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN014959400OtherMEDICAL ASSISTANCE MHCP
MN130952OtherU CARE
MN0492456Medicaid
MN20358-02OtherBHP
MN028H0HAOtherBCBS
6151196OtherUBH
MN028H1FROtherBCBS
MN1028022OtherMENTAL HEALTH
MNHP 33776OtherMENTAL HEALTH