Healthcare Provider Details

I. General information

NPI: 1366626095
Provider Name (Legal Business Name): AMV PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 FRANCE AVE S SUITE #224
EDINA MN
55435-4300
US

IV. Provider business mailing address

5916 COLFAX AVE S
MINNEAPOLIS MN
55419-2104
US

V. Phone/Fax

Practice location:
  • Phone: 612-636-7915
  • Fax: 952-831-0443
Mailing address:
  • Phone: 612-636-7915
  • Fax: 952-831-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4735
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number4735
License Number StateMN

VIII. Authorized Official

Name: DR. ANDREA M VICTOR
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D., LP
Phone: 612-636-7915