Healthcare Provider Details

I. General information

NPI: 1700852266
Provider Name (Legal Business Name): DAVID J LESAR EDD LP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 15TH ST N
SAINT CLOUD MN
56303-1802
US

IV. Provider business mailing address

8100 34TH AVE S MC21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5200
  • Fax: 320-203-2113
Mailing address:
  • Phone: 952-883-7172
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP2376
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: