Basic Information
| Provider Information | |||||||||
| NPI: | 1972755114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAISTROVICH | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | LEAF | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5125 COUNTY ROAD 101 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553454156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529327277 | ||||||||
| FaxNumber: | 9529329827 | ||||||||
| Practice Location | |||||||||
| Address1: | 5125 COUNTY ROAD 101 | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553454156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529327277 | ||||||||
| FaxNumber: | 9529329827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | CC01058 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.