Healthcare Provider Details

I. General information

NPI: 1982988259
Provider Name (Legal Business Name): ANDRE PERI PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 07/23/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

IV. Provider business mailing address

10427 BROWN FARM CIR
EDEN PRAIRIE MN
55347-4926
US

V. Phone/Fax

Practice location:
  • Phone: 612-721-9800
  • Fax:
Mailing address:
  • Phone: 301-213-3734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1000841
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number05040
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6146
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: