1609872589 NPI number — DR. LISA SHARON SQUIRE PH.D., L.P.

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 1609872589 NPI number — DR. LISA SHARON SQUIRE PH.D., L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SQUIRE
Provider First Name:
LISA
Provider Middle Name:
SHARON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., L.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SQUIRE PHD LP
Provider Other First Name:
LISA
Provider Other Middle Name:
S.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD LP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609872589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7800 METRO PKWY
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-854-2440
Provider Business Mailing Address Fax Number:
952-854-2465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7800 METRO PKWY
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55425-1509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-854-2440
Provider Business Practice Location Address Fax Number:
952-854-2465
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  MNLP0204 , 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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