Healthcare Provider Details

I. General information

NPI: 1740559699
Provider Name (Legal Business Name): CONSULTING PSYCHOLOGISTS ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DALE ST N 213
SAINT PAUL MN
55103-1914
US

IV. Provider business mailing address

2870 HIGHVIEW TER
EAGAN MN
55121-1110
US

V. Phone/Fax

Practice location:
  • Phone: 651-225-0954
  • Fax:
Mailing address:
  • Phone: 651-225-0854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberLP1135
License Number StateMN

VIII. Authorized Official

Name: DR. BRUCE KEITH THORDAL
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 651-225-0854