Healthcare Provider Details

I. General information

NPI: 1275575037
Provider Name (Legal Business Name): LORI ELMER MIGDAL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 COMMERCE DR STE 260
WOODBURY MN
55125-4502
US

IV. Provider business mailing address

680 COMMERCE DR STE 260
WOODBURY MN
55125-4502
US

V. Phone/Fax

Practice location:
  • Phone: 651-395-9442
  • Fax:
Mailing address:
  • Phone: 651-395-9442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number011396
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number011396
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5218
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: