Provider Demographics
NPI:1013215136
Name:STEPHEN M. HJEMBOE, PH.D., LLC
Entity Type:Organization
Organization Name:STEPHEN M. HJEMBOE, PH.D., LLC
Other - Org Name:ST. PAUL PSYCHOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:HJEMBOE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-776-2648
Mailing Address - Street 1:54 BATES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-6339
Mailing Address - Country:US
Mailing Address - Phone:651-776-2648
Mailing Address - Fax:651-778-1458
Practice Address - Street 1:570 ASBURY ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1849
Practice Address - Country:US
Practice Address - Phone:651-776-2648
Practice Address - Fax:651-778-1458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-14
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN705714800Medicaid
MNHP22394OtherHEAL THPARTNERS
MNHP22394OtherHEAL THPARTNERS