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General NPI Number Information
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NPI Number | 1104901172
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Entity Type | Individual
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Provider Name | WALTER O BOCKTING PHD
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Gender | Male
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Dates
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Enumeration Date | 10/26/2006
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Last Update Date | 03/19/2024
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Provider Practice Location Address
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Address Line | 1300 S 2ND ST SUITE 180
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City | MINNEAPOLIS
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State | MN
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Zip | 55454-1075
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Country | US
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Telephone | 612-625-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 3989 CENTRAL AVE NE SUITE 300
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City | COLUMBIA HEIGHTS
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State | MN
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Zip | 55421-3900
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Country | US
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Telephone | 612-625-1500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | LP2505
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP2505
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 020658
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License Number State | NY
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