MEDICARE: ROBERT J ELLISON L.P.

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	103TC0700X	Clinical Psychologist	LP1486	MN

General Provider Information

NPI Number	:	1265526412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT J ELLISON L.P.

Provider Business Mailing Address
First Line	:	1601 HIGHWAY 13 E
Second Line	:	STE. 101
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-6865
Country	:	US
Telephone Number	:	952-895-9200
Fax Number	:	952-895-1946

Provider Business Practice Location Address
First Line	:	1601 HIGHWAY 13 E
Second Line	:	STE. 101
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-6865
Country	:	US
Telephone Number	:	952-895-9200
Fax Number	:	952-895-1946

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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