Healthcare Provider Details

I. General information

NPI: 1598704082
Provider Name (Legal Business Name): DAVID JUDSON DECKER MA, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 DAYTON AVE SUITE 321
SAINT PAUL MN
55104-6206
US

IV. Provider business mailing address

1619 DAYTON AVE SUITE 321
SAINT PAUL MN
55104-6206
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-4325
  • Fax: 651-646-4325
Mailing address:
  • Phone: 651-646-4325
  • Fax: 651-646-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP 0342
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: