Healthcare Provider Details

I. General information

NPI: 1992940746
Provider Name (Legal Business Name): JUSTIN COULTER PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7236 FORESTVIEW LANE N.
MAPLE GROVE MN
55369
US

IV. Provider business mailing address

521 2ND ST SE # 100
MINNEAPOLIS MN
55414-2290
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-4167
  • Fax: 763-416-4137
Mailing address:
  • Phone: 651-235-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5543
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: