=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043344849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ED YERKA PSYCHOLOGICAL CONSULTANT, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 04/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 238 W MAIN ST STE 7
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-1398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-401-2026
-----------------------------------------------------
Fax | 662-601-3968
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 W THOMAS AVE
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56258-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-530-2837
-----------------------------------------------------
Fax | 866-260-1396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWIN YERKA
-----------------------------------------------------
Credential | LP
-----------------------------------------------------
Telephone | 507-530-2837
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | LP 4390
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------