Healthcare Provider Details

I. General information

NPI: 1689034910
Provider Name (Legal Business Name): BOURDEAUX PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 311TH ST
STACY MN
55079-9299
US

IV. Provider business mailing address

4425 311TH ST
STACY MN
55079-9299
US

V. Phone/Fax

Practice location:
  • Phone: 612-326-0775
  • Fax: 161-243-5411
Mailing address:
  • Phone: 612-326-0775
  • Fax: 161-243-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5690
License Number StateMN

VIII. Authorized Official

Name: DR. MONIQUE MARIE BOURDEAUX-COLBURN
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D, LP
Phone: 612-326-0775