MEDICARE: MR. EARL NOLTING PHD LP

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	LP0594	MN

General Provider Information

NPI Number	:	1720183478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EARL NOLTING PHD LP

Provider Business Mailing Address
First Line	:	3336 LAKE JOHANNA BLVD
Second Line	:
City	:	ST PAUL
State	:	MN
Zip	:	55112-7942
Country	:	US
Telephone Number	:	651-633-4333
Fax Number	:	651-634-3712

Provider Business Practice Location Address
First Line	:	3116 FAIRVIEW AVE NORTH
Second Line	:
City	:	ST PAUL
State	:	MN
Zip	:	55113-1203
Country	:	US
Telephone Number	:	651-636-9100
Fax Number	:	651-634-3712

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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