Healthcare Provider Details

I. General information

NPI: 1124129382
Provider Name (Legal Business Name): GARY MICHAEL GOLDETSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE TMD CLINIC
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

515 DELAWARE ST SE TMD CLINIC
MINNEAPOLIS MN
55455-0357
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberLPO 508
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: