Healthcare Provider Details

I. General information

NPI: 1063471506
Provider Name (Legal Business Name): BONNIE L CARLSON-GREEN PHD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 NORTH SMITH AVENUE CHILDRENS SPECIALTY CLINIC PSYCHOLOGICAL SERVICES STPL
ST PAUL MN
55102
US

IV. Provider business mailing address

2910 CENTRE POINTE DRIVE 35-121A CHILDRENS HEALTH CARE
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6720
  • Fax: 651-220-6707
Mailing address:
  • Phone: 651-855-2327
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberLP3309
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: