Healthcare Provider Details

I. General information

NPI: 1407123425
Provider Name (Legal Business Name): CENTER FOR PSYCHOLOGICAL CONSULTATION, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
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 TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP0709
License Number StateMN

VIII. Authorized Official

Name: DR. JAMES EDWARD BOSCARDIN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 612-719-0856