Healthcare Provider Details

I. General information

NPI: 1720635519
Provider Name (Legal Business Name): SOUTHERN MINNESOTA PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 N MAIN ST STE 104L
AUSTIN MN
55912-3478
US

IV. Provider business mailing address

2701 9TH AVE SW
AUSTIN MN
55912-5406
US

V. Phone/Fax

Practice location:
  • Phone: 507-434-1092
  • Fax:
Mailing address:
  • Phone: 507-438-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY PATRICK LANG
Title or Position: CLINICAL PSYCHOLOGIST
Credential:
Phone: 507-434-1092