Healthcare Provider Details

I. General information

NPI: 1265802532
Provider Name (Legal Business Name): STILLWATER PSYCHOLOGICAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 COUNTY ROAD B W STE 102
ROSEVILLE MN
55113-4053
US

IV. Provider business mailing address

1611 COUNTY ROAD B W STE 102
ROSEVILLE MN
55113-4053
US

V. Phone/Fax

Practice location:
  • Phone: 651-356-4436
  • Fax: 651-348-8349
Mailing address:
  • Phone: 651-356-4436
  • Fax: 651-348-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12610
License Number StateMN

VIII. Authorized Official

Name: CHRISTOPHER MCCALLA
Title or Position: OWNER
Credential:
Phone: 651-356-4436