Healthcare Provider Details

I. General information

NPI: 1588741292
Provider Name (Legal Business Name): ASSOCIATED CLINIC OF PSYCHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4027 COUNTY ROAD 25
ST LOUIS PARK MN
55416
US

IV. Provider business mailing address

4240 PARK GLEN RD
ST LOUIS PARK MN
55416-4758
US

V. Phone/Fax

Practice location:
  • Phone: 612-925-6033
  • Fax: 612-925-8496
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number811029-1-MHC
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number811029-1-MHC
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number811029-1-MHC
License Number StateMN

VIII. Authorized Official

Name: DR. JOHN E BROSE
Title or Position: CEO
Credential: PHD LP
Phone: 612-925-6033