MEDICARE: MR. DENNIS LEE FLOM MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP3777	MN

General Provider Information

NPI Number	:	1114087236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS LEE FLOM MA

Provider Business Mailing Address
First Line	:	1520 XENIA AVE N
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4433
Country	:	US
Telephone Number	:	763-544-8882
Fax Number	:	763-545-9807

Provider Business Practice Location Address
First Line	:	1520 XENIA AVE N
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4433
Country	:	US
Telephone Number	:	763-544-8882
Fax Number	:	763-545-9807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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