ST. PAUL NEUROPSYCHOLOGY SERVICES, P.A. - NPI NUMBER 1467439067

Summary

Provider Name: ST. PAUL NEUROPSYCHOLOGY SERVICES, P.A.

NPI Number: 1467439067

Clasification: Psychologist (103TC0700X)

Specialization: Clinical

Address:
1789 WOODLANE DR
SUITE C
WOODBURY, MN
ZIP 55125

Phone Number: (651) 501-4957



Detailed Information

ST. PAUL NEUROPSYCHOLOGY SERVICES, P.A. is a clinical psychologist in Woodbury, MN. The assigned NPI number for this provider is 1467439067 and is registered as an organization entity type and is a multi-specialty group.

The provider's business address is:

1789 WOODLANE DR
SUITE C
WOODBURY, MN
ZIP 55125-910
Phone: (651) 501-4957

The provider's authorized official is Laura Mcdaniels .
The authorized official title is Owner and has the following contact phone number (651) 501-4957.

The enumeration date for this NPI number is 12/27/2005 and was last updated on 7/8/2007.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 103TC0700X Psychologist Clinical X
2 103G00000X Clinical Neuropsychologist X
3 103T00000X Psychologist X

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 P00092642 OTHER MN RAILROAD MEDICARE
2 141783 OTHER MN UCARE AND BHP
3 61-78127 OTHER MN MEDICA AND UBH
4 C04138 MEDICARE ID-TYPE UNSPECIFIED MN
5 103221 OTHER MN HEALTHPARTNERS
6 277S5MC OTHER MN BLUE CROSS

NPI Record

No. Field Name Field Value
1 NPI 1467439067
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name ST. PAUL NEUROPSYCHOLOGY SERVICES, P.A.
5 Provider First Line Business Practice Location Address 1789 WOODLANE DR
6 Provider Second Line Business Practice Location Address SUITE C
7 Provider Business Practice Location Address City Name WOODBURY
8 Provider Business Practice Location Address State Name MN
9 Provider Business Practice Location Address Postal Code 551253910
10 Provider Business Practice Location Address Country Code If outside U S US
11 Provider Business Practice Location Address Telephone Number 6515014957
12 Provider Enumeration Date 12/27/2005
13 Last Update Date 7/8/2007
14 Authorized Official Last Name MCDANIELS
15 Authorized Official First Name LAURA
16 Authorized Official Title or Position OWNER
17 Authorized Official Telephone Number 6515014957
18 Healthcare Provider Taxonomy Code 1 103TC0700X
19 Healthcare Provider Primary Taxonomy Switch 1 X
20 Healthcare Provider Taxonomy Code 2 103G00000X
21 Healthcare Provider Primary Taxonomy Switch 2 X
22 Healthcare Provider Taxonomy Code 3 103T00000X
23 Healthcare Provider Primary Taxonomy Switch 3 X
24 Other Provider Identifier 1 P00092642
25 Other Provider Identifier Type Code 1 01
26 Other Provider Identifier State 1 MN
27 Other Provider Identifier Issuer 1 RAILROAD MEDICARE
28 Other Provider Identifier 2 141783
29 Other Provider Identifier Type Code 2 01
30 Other Provider Identifier State 2 MN
31 Other Provider Identifier Issuer 2 UCARE AND BHP
32 Other Provider Identifier 3 61-78127
33 Other Provider Identifier Type Code 3 01
34 Other Provider Identifier State 3 MN
35 Other Provider Identifier Issuer 3 MEDICA AND UBH
36 Other Provider Identifier 4 C04138
37 Other Provider Identifier Type Code 4 04
38 Other Provider Identifier State 4 MN
39 Other Provider Identifier 5 103221
40 Other Provider Identifier Type Code 5 01
41 Other Provider Identifier State 5 MN
42 Other Provider Identifier Issuer 5 HEALTHPARTNERS
43 Other Provider Identifier 6 277S5MC
44 Other Provider Identifier Type Code 6 01
45 Other Provider Identifier State 6 MN
46 Other Provider Identifier Issuer 6 BLUE CROSS
47 Authorized Official Credential Text PSY.D., L.P.
48 Healthcare Provider Taxonomy Group 1 193200000X MULTI-SPECIALTY GROUP
49 Healthcare Provider Taxonomy Group 2 193200000X MULTI-SPECIALTY GROUP
50 Healthcare Provider Taxonomy Group 3 193200000X MULTI-SPECIALTY GROUP

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This page was last updated on: 8/12/2014
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