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NPI Code Detail

MEDICARE: PSYCHOLOGY SERVICES OF MINNESOTA, PLLC

MEDICARE: PSYCHOLOGY SERVICES OF MINNESOTA, PLLC
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
1103T00000XPsychologist3464MN

General Provider Information

NPI Number : 1841780335
Entity Type Code : Organization
Provider Name (Legal Business Name) : PSYCHOLOGY SERVICES OF MINNESOTA, PLLC
Provider Business Mailing Address
First Line : 15748 BIRCHWOOD LN
Second Line :
City : BRAINERD
State : MN
Zip : 56401-6176
Country : US
Telephone Number : 218-330-7867
Fax Number :
Provider Business Practice Location Address
First Line : 804 WRIGHT ST
Second Line :
City : BRAINERD
State : MN
Zip : 56401-4441
Country : US
Telephone Number : 218-829-1407
Fax Number :
Authorized Official
Title or Position : PSYCHOLOGIST
Name : KEVIN JAMES EDWARDS
Credential : PH.D., LP
Telephone Number : 218-330-7867
Provider Enumeration Date : 05/10/2018
Last Update Date : 04/11/2019

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