Healthcare Provider Details

I. General information

NPI: 1861914608
Provider Name (Legal Business Name): NORTHSTAR PSYCHOLOGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LONG LAKE RD STE 320
NEW BRIGHTON MN
55112-6439
US

IV. Provider business mailing address

2055 XAVIER ST APT 217
BISMARCK ND
58501-1413
US

V. Phone/Fax

Practice location:
  • Phone: 651-482-9361
  • Fax:
Mailing address:
  • Phone: 701-415-8271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TODD M. WAHL
Title or Position: PSYCHOLOGIST
Credential:
Phone: 701-415-8271