Provider Demographics
NPI:1447524285
Name:FIRESIDE COUNSELING LLC
Entity type:Organization
Organization Name:FIRESIDE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FREITAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:952-442-0040
Mailing Address - Street 1:9350 OAK AVE
Mailing Address - Street 2:PO BOX 42
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-5500
Mailing Address - Country:US
Mailing Address - Phone:952-270-2086
Mailing Address - Fax:
Practice Address - Street 1:9350 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-5500
Practice Address - Country:US
Practice Address - Phone:952-442-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
680002139OtherMEDICARE