MEDICARE: COLLIN DAVIDSON PHD

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
2	103TB0200X	Cognitive & Behavioral Psychologist	LP5748	MN

General Provider Information

NPI Number	:	1821364001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN DAVIDSON PHD

Provider Business Mailing Address
First Line	:	4419 WENTWORTH AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-4941
Country	:	US
Telephone Number	:	405-612-3428
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 W LAKE ST STE 201
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3565
Country	:	US
Telephone Number	:	303-399-8020
Fax Number	:

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

Provider Enumeration Date	:	04/01/2012
Last Update Date	:	07/04/2019

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