Healthcare Provider Details

I. General information

NPI: 1679607832
Provider Name (Legal Business Name): JEAN M. BIRBILIS PH.D., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 UPPER AFTON RD E STE 101
MAPLEWOOD MN
55119-4760
US

IV. Provider business mailing address

2721 UPPER AFTON RD E STE 101
MAPLEWOOD MN
55119-4760
US

V. Phone/Fax

Practice location:
  • Phone: 651-739-6167
  • Fax:
Mailing address:
  • Phone: 651-739-6167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0392
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: