Healthcare Provider Details

I. General information

NPI: 1992029300
Provider Name (Legal Business Name): KRISTIN MARIE NELSON PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KRISTIN MARIE GRANDBOIS

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 MEMBERS PKWY NW
ROCHESTER MN
55901-8381
US

IV. Provider business mailing address

9400 ZANE AVE N
BROOKLYN PARK MN
55443-1814
US

V. Phone/Fax

Practice location:
  • Phone: 507-218-3701
  • Fax: 507-258-5503
Mailing address:
  • Phone: 763-762-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5235
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: