MEDICARE: DEREK EVAN PROWE PSYD

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	LP5238	MN

General Provider Information

NPI Number	:	1699924639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK EVAN PROWE PSYD

Provider Business Mailing Address
First Line	:	4749 CHICAGO AVE STE 1D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-4181
Country	:	US
Telephone Number	:	612-656-9122
Fax Number	:

Provider Business Practice Location Address
First Line	:	4749 CHICAGO AVE STE 1D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-4181
Country	:	US
Telephone Number	:	612-656-9122
Fax Number	:

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

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	02/25/2016

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