Healthcare Provider Details

I. General information

NPI: 1225628217
Provider Name (Legal Business Name): MS. ASHLEY NICOLE CERMAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 HAMEL RD
MEDINA MN
55340-9535
US

IV. Provider business mailing address

6552 CARRIAGE WAY
CORCORAN MN
55340-4443
US

V. Phone/Fax

Practice location:
  • Phone: 612-756-9107
  • Fax:
Mailing address:
  • Phone: 612-756-9107
  • Fax: 621-235-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: