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General NPI Number Information
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NPI Number | 1164559241
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Entity Type | Individual
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Provider Name | JOHN MICHAEL IMP PHD., L.P.
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Gender | Male
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 300 3RD AVE SE SUITE 405
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City | ROCHESTER
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State | MN
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Zip | 55904-4619
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Country | US
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Telephone | 507-288-8544
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Fax | 507-288-8545
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Provider Business Mailing Address
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Address Line | 1357 WINDBREAK CT NE
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City | ROCHESTER
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State | MN
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Zip | 55906-8587
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Country | US
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Telephone | 507-289-5409
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP2523
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License Number State | MN
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