=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497820039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNESOTA PSYCHOLOGICAL RESOURCES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12805 HIGHWAY 55 SUITE 211
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-550-9005
-----------------------------------------------------
Fax | 763-559-2118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12805 HIGHWAY 55 SUITE 211
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-550-9005
-----------------------------------------------------
Fax | 763-559-2118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DAVID MELLBERG
-----------------------------------------------------
Credential | PH.D., L.P.
-----------------------------------------------------
Telephone | 763-550-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 801884-1-MHC
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------