Basic Information
| Provider Information | |||||||||
| NPI: | 1265463137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREITAG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 2312 SOUTH 6TH STREET, SUITE F256 / 2B WEST | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122739800 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 2312 SOUTH 6TH STREET, SUITE F256 / 2B WEST | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4319 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0492456 | 05 | MT | MEDICAID | 1028022 | 01 | MN | PREFERRED ONE | OTHER | 130952 | 01 | MN | UCARE | OTHER | 61-57516 | 01 | MN | MEDICA CHOICE & PRIMARY | OTHER | 1382591 | 01 | MN | ARAZ | OTHER | 74G37FR | 01 | MN | BCBS | OTHER | HP33776 | 01 | MN | HEALTHPARTNERS | OTHER |