MEDICARE: LAUREL PSYCHOLOGICAL SERVICES, PA

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	LP1642	MN

General Provider Information

NPI Number	:	1154641132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUREL PSYCHOLOGICAL SERVICES, PA

Provider Business Mailing Address
First Line	:	1108 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2618
Country	:	US
Telephone Number	:	651-228-0218
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2618
Country	:	US
Telephone Number	:	651-228-0218
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN P ELLIS
Credential	:	PHD
Telephone Number	:	651-228-0218

Provider Enumeration Date	:	06/01/2010
Last Update Date	:	06/01/2010

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