Healthcare Provider Details

I. General information

NPI: 1144248063
Provider Name (Legal Business Name): MELODIE SUE BRODEN PH.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELODIE SUE VANKAMPEN

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR 116B
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1 VETERANS DR 116B
MINNEAPOLIS MN
55417-2309
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-5753
  • Fax: 612-467-5309
Mailing address:
  • Phone: 612-467-5753
  • Fax: 612-467-5309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4214
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: