MEDICARE: PATRICIA VERBY PSYCHOLOGICAL SERVICES INC

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	LP2905	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C04494	OTHER	MN	MEDICARE IDENTIFICATION #

General Provider Information

NPI Number	:	1245312818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRICIA VERBY PSYCHOLOGICAL SERVICES INC

Provider Business Mailing Address
First Line	:	1751 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-892-7690
Fax Number	:	952-898-4930

Provider Business Practice Location Address
First Line	:	1751 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-892-7690
Fax Number	:	952-898-4930

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	MS. PATRICIA A VERBY
Credential	:	MA
Telephone Number	:	952-892-7690

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	02/22/2008

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