Healthcare Provider Details

I. General information

NPI: 1639227135
Provider Name (Legal Business Name): JEREMY WILLIAM RONDORF PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 PLEASANT VALLEY RD
CENTER CITY MN
55012-9640
US

IV. Provider business mailing address

15245 PLEASANT VALLEY RD
CENTER CITY MN
55012-9640
US

V. Phone/Fax

Practice location:
  • Phone: 651-213-4184
  • Fax: 651-213-4411
Mailing address:
  • Phone: 651-213-4184
  • Fax: 651-213-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: