Provider Demographics
NPI:1073506846
Name:VIKESLAND, GARY D (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:VIKESLAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10700 OLD COUNTY RD 15
Mailing Address - Street 2:SUITE 170
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-525-8590
Mailing Address - Fax:763-525-8592
Practice Address - Street 1:10700 OLD COUNTY ROAD 15 STE 170
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-8709
Practice Address - Country:US
Practice Address - Phone:763-525-8590
Practice Address - Fax:763-525-8592
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3160103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN069523800Medicaid