Healthcare Provider Details

I. General information

NPI: 1780177337
Provider Name (Legal Business Name): DEVELOPING MINDS PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 REPUBLIC AVE
ST LOUIS PARK MN
55426-4154
US

IV. Provider business mailing address

3340 REPUBLIC AVE STE 120
ST LOUIS PARK MN
55426-4189
US

V. Phone/Fax

Practice location:
  • Phone: 517-977-6571
  • Fax:
Mailing address:
  • Phone: 612-758-0583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberLP6081
License Number StateMN

VIII. Authorized Official

Name: DR. GABRIEL WATSON
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 612-758-0583