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General NPI Number Information
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NPI Number | 1740821214
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Entity Type | Individual
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Provider Name | PHILIP DAVID IMHOLTE PSYD
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Gender | Male
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Dates
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Enumeration Date | 10/04/2019
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Last Update Date | 12/07/2022
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Provider Practice Location Address
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Address Line | 3259 ZARTHAN AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55416-2062
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Country | US
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Telephone | 320-828-0864
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Fax |
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Provider Business Mailing Address
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Address Line | 3259 ZARTHAN AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55416-2062
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Country | US
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Telephone | 320-828-0864
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 004270
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LP6876
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License Number State | MN
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