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General NPI Number Information
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NPI Number | 1285290072
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Entity Type | Organization
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Legal Business Name | SUMMIT CLINICS PLLC
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Dates
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Enumeration Date | 05/16/2019
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Last Update Date | 05/16/2019
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Provider Practice Location Address
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Address Line | 2115 COUNTY ROAD D E STE C
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City | MAPLEWOOD
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State | MN
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Zip | 55109-5353
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Country | US
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Telephone | 651-955-6747
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Fax |
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Provider Business Mailing Address
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Address Line | 2115 COUNTY ROAD D E STE C100
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City | MAPLEWOOD
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State | MN
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Zip | 55109-5354
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | VAMSI DWARAM
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Credential |
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Telephone | 651-955-6747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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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 |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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