Healthcare Provider Details

I. General information

NPI: 1770832875
Provider Name (Legal Business Name): ALLEN STOCK LICENSED PSYCHOLOGIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 03/16/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 WAYZATA BLVD STE 767
ST LOUIS PARK MN
55416-1222
US

IV. Provider business mailing address

5775 WAYZATA BLVD STE 767
ST LOUIS PARK MN
55416-1222
US

V. Phone/Fax

Practice location:
  • Phone: 612-799-6263
  • Fax:
Mailing address:
  • Phone: 612-799-6263
  • Fax: 888-827-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP1450
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: