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General NPI Number Information
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NPI Number | 1780177337
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Entity Type | Organization
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Legal Business Name | DEVELOPING MINDS PSYCHOLOGY, PLLC
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Dates
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Enumeration Date | 06/08/2018
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Last Update Date | 11/08/2018
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Provider Practice Location Address
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Address Line | 3340 REPUBLIC AVE
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City | ST LOUIS PARK
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State | MN
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Zip | 55426-4154
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Country | US
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Telephone | 517-977-6571
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Fax |
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Provider Business Mailing Address
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Address Line | 3340 REPUBLIC AVE STE 120
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City | ST LOUIS PARK
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State | MN
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Zip | 55426-4189
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Country | US
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Telephone | 612-758-0583
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. GABRIEL WATSON
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Credential | PHD
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Telephone | 612-758-0583
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | LP6081
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License Number State | MN
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