=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912181538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. CROIX PSYCHOLOGICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2007
-----------------------------------------------------
Last Update Date | 12/18/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 258 RIVERSIDE DR
-----------------------------------------------------
City | RIVER FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54022-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-425-7031
-----------------------------------------------------
Fax | 715-425-1055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 425
-----------------------------------------------------
City | RIVER FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54022-0425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-425-7031
-----------------------------------------------------
Fax | 715-425-1055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | WI LIC. PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JOHN B. HAMANN
-----------------------------------------------------
Credential | ED.D
-----------------------------------------------------
Telephone | 715-425-7031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 371-057
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------