Healthcare Provider Details

I. General information

NPI: 1265610851
Provider Name (Legal Business Name): TATYANA V. AVDEYEVA PH.D., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7372 KIRKWOOD CT N
MAPLE GROVE MN
55369-5202
US

IV. Provider business mailing address

2285 STEWART AVE APT 2404
SAINT PAUL MN
55116-3173
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-4167
  • Fax:
Mailing address:
  • Phone: 651-699-4190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4809
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: