MEDICARE: HACHIYA PSYCHOLOGICAL SERVICES

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	LP5674	MN

General Provider Information

NPI Number	:	1477962488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HACHIYA PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	2318 LINNER RD
Second Line	:
City	:	WAYZATA
State	:	MN
Zip	:	55391-2225
Country	:	US
Telephone Number	:	612-226-3915
Fax Number	:

Provider Business Practice Location Address
First Line	:	3414 W 47TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-1721
Country	:	US
Telephone Number	:	612-226-3915
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. ANDREW JOHN HACHIYA
Credential	:	PSYD, LP
Telephone Number	:	612-226-3915

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	08/05/2014

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