Basic Information
Provider Information | |||||||||
NPI: | 1699792606 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RISSE | ||||||||
FirstName: | GAIL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551131306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512415290 | ||||||||
FaxNumber: | 6513778474 | ||||||||
Practice Location | |||||||||
Address1: | 2720 FAIRVIEW AVE N STE 100 | ||||||||
Address2: |   | ||||||||
City: | ROSEVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 551131306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512415290 | ||||||||
FaxNumber: | 6512415140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | LP1122 | MN | Y |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
ID Information
ID | Type | State | Issuer | Description | 703752000 | 05 | MN |   | MEDICAID |