MEDICARE: MR. RICHARD JOHN SCANLON JR. M.A., 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	103T00000X	Psychologist	LP2556	MN

General Provider Information

NPI Number	:	1689668931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD JOHN SCANLON JR. M.A., L.P.

Provider Business Mailing Address
First Line	:	8120 165TH ST E
Second Line	:
City	:	PRIOR LAKE
State	:	MN
Zip	:	55372-4100
Country	:	US
Telephone Number	:	612-669-3759
Fax Number	:

Provider Business Practice Location Address
First Line	:	6542 REGENCY LN
Second Line	:	#212
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7847
Country	:	US
Telephone Number	:	612-669-3759
Fax Number	:

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	07/08/2007

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