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General NPI Number Information
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NPI Number | 1083074371
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Entity Type | Organization
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Legal Business Name | DEREK PROWE LLC
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Dates
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Enumeration Date | 02/29/2016
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Last Update Date | 02/29/2016
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Provider Practice Location Address
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Address Line | 4749 CHICAGO AVE SUITE 1D
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-3556
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Country | US
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Telephone | 612-656-9122
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Fax |
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Provider Business Mailing Address
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Address Line | 4749 CHICAGO AVE SUITE 1D
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City | MINNEAPOLIS
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State | MN
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Zip | 55407-3556
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Country | US
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Telephone | 612-656-9122
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEREK EVAN PROWE
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Credential | PSYD
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Telephone | 612-656-9122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP5238
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License Number State | MN
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