Healthcare Provider Details

I. General information

NPI: 1912730318
Provider Name (Legal Business Name): THOMAS DALE SHYPULSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10273 YELLOW CIRCLE DR
MINNETONKA MN
55343-9144
US

IV. Provider business mailing address

14663 MERCANTILE DR N
HUGO MN
55038-4559
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-9805
  • Fax:
Mailing address:
  • Phone: 612-405-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: