1295167880 NPI number — DICKSON PSYCHIATRIC SERVICES, PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295167880 NPI number — DICKSON PSYCHIATRIC SERVICES, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DICKSON PSYCHIATRIC SERVICES, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295167880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6357 MERRIMAC LN N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55311-3835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-256-7570
Provider Business Mailing Address Fax Number:
877-514-9201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 BAKER RD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55343-8688
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-200-6161
Provider Business Practice Location Address Fax Number:
877-514-9201
Provider Enumeration Date:
08/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DICKSON
Authorized Official First Name:
TODD
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
218-256-7570

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  CNP-1591 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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