Healthcare Provider Details

I. General information

NPI: 1124398607
Provider Name (Legal Business Name): STONE ARCH PSYCHOLOGY AND HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MAIN ST SE STE 400
MINNEAPOLIS MN
55414
US

IV. Provider business mailing address

219 MAIN ST SE STE 400
MINNEAPOLIS MN
55414-2151
US

V. Phone/Fax

Practice location:
  • Phone: 612-886-2524
  • Fax: 612-886-2538
Mailing address:
  • Phone: 612-886-2524
  • Fax: 612-886-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3594
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberLP3594
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP3594
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3594
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP3594
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLP3594
License Number StateMN
# 7
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3594
License Number StateMN

VIII. Authorized Official

Name: MS. SUSAN GUSTAFSON
Title or Position: PSYCHOLOGIST
Credential: PSD. LP.
Phone: 612-886-2524