Healthcare Provider Details

I. General information

NPI: 1184697427
Provider Name (Legal Business Name): JOHN M SALTER PSYD LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 HUDSON BLVD HEALTHPARTNERS REGIONS BEHAVIORAL HEALTH-WOODBURY
LAKE ELMO MN
55042-8706
US

IV. Provider business mailing address

8100 34TH AVE S MC21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-8580
  • Fax: 651-730-1700
Mailing address:
  • Phone: 952-883-7172
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4324
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: