Healthcare Provider Details

I. General information

NPI: 1073506846
Provider Name (Legal Business Name): GARY D VIKESLAND PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 OLD COUNTY ROAD 15 STE 170
PLYMOUTH MN
55441-8709
US

IV. Provider business mailing address

10700 OLD COUNTY RD 15 SUITE 170
PLYMOUTH MN
55441
US

V. Phone/Fax

Practice location:
  • Phone: 763-525-8590
  • Fax: 763-525-8592
Mailing address:
  • Phone: 763-525-8590
  • Fax: 763-525-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP3160
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: