1841780335 NPI number — PSYCHOLOGY SERVICES OF MINNESOTA, PLLC

Table of content: (NPI 1841780335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841780335 NPI number — PSYCHOLOGY SERVICES OF MINNESOTA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHOLOGY SERVICES OF MINNESOTA, 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:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1841780335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15748 BIRCHWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAINERD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56401-6176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-330-7867
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 WRIGHT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-4441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-829-1407
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
218-330-7867

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  3464 , 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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