MEDICARE: DEVELOPMENTAL DIAGNOSTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103G00000X	Clinical Neuropsychologist
2	106H00000X	Marriage & Family Therapist
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1831723808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVELOPMENTAL DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	15 E MINNESOTA ST STE 105
Second Line	:
City	:	SAINT JOSEPH
State	:	MN
Zip	:	56374-4691
Country	:	US
Telephone Number	:	320-363-8055
Fax Number	:	320-363-8056

Provider Business Practice Location Address
First Line	:	15 E MINNESOTA ST STE 105
Second Line	:
City	:	SAINT JOSEPH
State	:	MN
Zip	:	56374-4691
Country	:	US
Telephone Number	:	320-363-8055
Fax Number	:	320-363-8056

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HOLLY HIEB CLAUSEN
Credential	:	PH.D.
Telephone Number	:	320-363-8055

Provider Enumeration Date	:	02/27/2020
Last Update Date	:	02/27/2020

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