MEDICARE: FEDERAL PRISON CAMP DULUTH

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1982971271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FEDERAL PRISON CAMP DULUTH

Provider Business Mailing Address
First Line	:	4464 RALSTON DRIVE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-1519
Country	:	US
Telephone Number	:	218-249-7452
Fax Number	:

Provider Business Practice Location Address
First Line	:	4464 RALSTON DR
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55811-1519
Country	:	US
Telephone Number	:	218-249-7452
Fax Number	:

Authorized Official
Title or Position	:	CHIEF PSYCHOLOGIST
Name	:	DR. TRACI SUE AMUNDSON
Credential	:	PSY.D.
Telephone Number	:	218-249-7452

Provider Enumeration Date	:	11/30/2011
Last Update Date	:	11/30/2011

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