Provider Demographics
NPI:1447507942
Name:LITTLE BIRD PSC
Entity type:Organization
Organization Name:LITTLE BIRD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DEONNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PANSCH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:218-760-9357
Mailing Address - Street 1:48858 US 71
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:MN
Mailing Address - Zip Code:56461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:48858 US 71
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:MN
Practice Address - Zip Code:56461-4879
Practice Address - Country:US
Practice Address - Phone:218-760-9357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19439261QD1600X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health