Healthcare Provider Details

I. General information

NPI: 1174641377
Provider Name (Legal Business Name): LEANNE C GOTH M.A., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

IV. Provider business mailing address

4717 OXBOROUGH GDNS
BROOKLYN PARK MN
55443-3994
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-1396
  • Fax: 763-257-0073
Mailing address:
  • Phone: 763-425-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4081
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: