=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295167880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DICKSON PSYCHIATRIC SERVICES, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2013
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 BAKER RD STE 200
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55343-8688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-200-6161
-----------------------------------------------------
Fax | 877-514-9201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6357 MERRIMAC LN N
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-3835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-256-7570
-----------------------------------------------------
Fax | 877-514-9201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | DR. TODD ALAN DICKSON
-----------------------------------------------------
Credential | DNP, APRN, PMHNP
-----------------------------------------------------
Telephone | 218-256-7570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP-1591
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------