1780177337 NPI number — DEVELOPING MINDS PSYCHOLOGY, PLLC

Table of content: (NPI 1780177337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780177337 NPI number — DEVELOPING MINDS PSYCHOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVELOPING MINDS PSYCHOLOGY, PLLC
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:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1780177337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 REPUBLIC AVE STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426-4189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-758-0583
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3340 REPUBLIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST LOUIS PARK
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-977-6571
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
GABRIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
612-758-0583

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  LP6081 , 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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