Healthcare Provider Details

I. General information

NPI: 1972682847
Provider Name (Legal Business Name): JAMES EDWARD BOSCARDIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8085 WAYZATA BLVD SUITE 100B
GOLDEN VALLEY MN
55426-1453
US

IV. Provider business mailing address

1092 LAWNVIEW AVE
SHOREVIEW MN
55126-8408
US

V. Phone/Fax

Practice location:
  • Phone: 612-719-0856
  • Fax: 651-484-8551
Mailing address:
  • Phone: 612-719-0856
  • Fax: 651-484-8551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberLP0709
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP0709
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP0709
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberLP0709
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0709
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLP0709
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: