MEDICARE: WEST METRO EDUCATION PROGRAM

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	103TS0200X	School Psychologist	475-878	MN

General Provider Information

NPI Number	:	1962831131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST METRO EDUCATION PROGRAM

Provider Business Mailing Address
First Line	:	10 S 10TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2033
Country	:	US
Telephone Number	:	612-752-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 S 10TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2033
Country	:	US
Telephone Number	:	612-752-7100
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF SPECIAL EDUCATION
Name	:	MR. DAVE HAVEMAN
Credential	:
Telephone Number	:	651-431-0680

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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