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NPI Code Detail

MEDICARE: RANDAL RICHARD STAATS

MEDICARE: RANDAL RICHARD STAATS
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
1103TC1900XCounseling PsychologistLP3816MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1760572317
Entity Type Code : Individual
Provider Name (Legal Business Name) : RANDAL RICHARD STAATS
Provider Business Mailing Address
First Line : 2414 PARK AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55404-3713
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2414 PARK AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55404-3713
Country : US
Telephone Number : 612-879-5362
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/13/2006
Last Update Date : 06/30/2010

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Directions to “ RANDAL RICHARD STAATS ” Practice Location

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