Healthcare Provider Details

I. General information

NPI: 1225233406
Provider Name (Legal Business Name): OLGA GRUN,PHD,PSYD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 DAYTON AVE SUITE 110
SAINT PAUL MN
55104-6206
US

IV. Provider business mailing address

1619 DAYTON AVE SUITE 110
SAINT PAUL MN
55104-6206
US

V. Phone/Fax

Practice location:
  • Phone: 651-523-8808
  • Fax: 651-523-8811
Mailing address:
  • Phone: 651-523-8808
  • Fax: 651-523-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP 4405
License Number StateMN

VIII. Authorized Official

Name: OLGA GRUN
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD, PSYD
Phone: 651-523-8808