MEDICARE: MINNESOTA CENTER FOR PSYCHOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP4454	MN

General Provider Information

NPI Number	:	1023258662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA CENTER FOR PSYCHOLOGY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 14107
Second Line	:	2387 UNIVERSITY AVENUE WEST
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-0107
Country	:	US
Telephone Number	:	952-200-7796
Fax Number	:

Provider Business Practice Location Address
First Line	:	2387 UNIVERSITY AVENUE WEST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-0107
Country	:	US
Telephone Number	:	952-200-7796
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	GERALD P CRIMMINS
Credential	:	PSY. D., L.P.
Telephone Number	:	952-200-7796

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	02/23/2009

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