=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689797136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM SCOTT SLATTERY PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 GRAND AVE STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-386-9682
-----------------------------------------------------
Fax | 651-305-6071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 GRAND AVE STE 102
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-386-9682
-----------------------------------------------------
Fax | 651-305-6071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | LP4325
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------