Healthcare Provider Details

I. General information

NPI: 1700973773
Provider Name (Legal Business Name): JAMES MICHAEL BALDUS PH.D., L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 MAYWOOD RD
MOUND MN
55364-1775
US

IV. Provider business mailing address

3032 HIGHVIEW LN
MOUND MN
55364-9422
US

V. Phone/Fax

Practice location:
  • Phone: 952-472-2408
  • Fax:
Mailing address:
  • Phone: 763-913-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP0796
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: