Healthcare Provider Details

I. General information

NPI: 1841497864
Provider Name (Legal Business Name): LAURA JEAN NIELSEN PSY.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA JEAN FARMER

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 SELBY AVE SUITE 306
SAINT PAUL MN
55102-1880
US

IV. Provider business mailing address

2602 13TH AVE E
SAINT PAUL MN
55109-2440
US

V. Phone/Fax

Practice location:
  • Phone: 651-769-3360
  • Fax:
Mailing address:
  • Phone: 651-769-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP 4759
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberLP 4759
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: