Healthcare Provider Details

I. General information

NPI: 1922898568
Provider Name (Legal Business Name): PHILIP JOHN MCDONALD MA, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

IV. Provider business mailing address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-1223
  • Fax:
Mailing address:
  • Phone: 612-596-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4982
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: