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General NPI Number Information
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NPI Number | 1649717778
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Entity Type | Organization
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Legal Business Name | GREAT LAKES NEUROBEHAVIORAL CENTER, PC
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Dates
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Enumeration Date | 01/27/2017
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Last Update Date | 03/03/2017
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Provider Practice Location Address
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Address Line | 7373 FRANCE AVE S SUITE 305
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City | EDINA
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State | MN
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Zip | 55435-4534
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Country | US
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Telephone | 612-382-7165
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Fax |
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Provider Business Mailing Address
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Address Line | 10195 INVER GROVE TRL
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City | INVER GROVE HEIGHTS
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State | MN
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Zip | 55076-3830
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Country | US
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Telephone | 612-382-7165
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Fax |
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Authorized Official
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Title or Position | NEUROPSYCHOLOGIST
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Name | DR. MELISSA FISCHER
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Credential | PHD
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Telephone | 612-382-7165
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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 | 6005
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License Number State | MN
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