Healthcare Provider Details

I. General information

NPI: 1609666791
Provider Name (Legal Business Name): DUSTIN FORE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 S FRONTAGE RD STE 150
HASTINGS MN
55033-2690
US

IV. Provider business mailing address

3644 DENNIS LN
WHITE BEAR LAKE MN
55110-4715
US

V. Phone/Fax

Practice location:
  • Phone: 651-505-3273
  • Fax:
Mailing address:
  • Phone: 320-279-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP7421
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: