Healthcare Provider Details

I. General information

NPI: 1316186877
Provider Name (Legal Business Name): CHARLES FIELDS MA, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13021 EVERGREEN DR
BAXTER MN
56425-7439
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW SUITE 110
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0231
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: