Healthcare Provider Details

I. General information

NPI: 1841382108
Provider Name (Legal Business Name): CORE PROFESSIONAL SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 OAK ST
BRAINERD MN
56401-3610
US

IV. Provider business mailing address

617 OAK ST
BRAINERD MN
56401-3610
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-7140
  • Fax:
Mailing address:
  • Phone: 218-829-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0103
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2585
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4659
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1885
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4630
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1517
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00131
License Number StateMN

VIII. Authorized Official

Name: BRENDA WEBER
Title or Position: OFFICE MANAGER
Credential:
Phone: 218-839-4785