Healthcare Provider Details

I. General information

NPI: 1558797936
Provider Name (Legal Business Name): MICKEY DINER STEIN M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date: 07/24/2014
Reactivation Date: 11/25/2014

III. Provider practice location address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

IV. Provider business mailing address

12800 WHITEWATER DR STE 100
MINNETONKA MN
55343-9347
US

V. Phone/Fax

Practice location:
  • Phone: 612-200-3950
  • Fax:
Mailing address:
  • Phone: 612-200-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP7103
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: