=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659539591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC CONSULTATION SPECIALISTS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2008
-----------------------------------------------------
Last Update Date | 06/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 FERNBROOK LANE N #120
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-559-7050
-----------------------------------------------------
Fax | 763-559-7060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 FERNBROOK LANE N #120
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-559-7050
-----------------------------------------------------
Fax | 763-559-7060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DR. SANDRA KUPERMAN SONDELL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 763-746-2707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | LP4585
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------