Healthcare Provider Details

I. General information

NPI: 1851775308
Provider Name (Legal Business Name): ROSS FULTON BARR PSY.D, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WHITEWATER DR STE 101
MINNETONKA MN
55343-4157
US

IV. Provider business mailing address

413 MADISON ST
ANOKA MN
55303-2518
US

V. Phone/Fax

Practice location:
  • Phone: 952-999-6097
  • Fax: 952-426-0508
Mailing address:
  • Phone: 612-719-8674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP6040
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6040
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: