Provider Demographics
NPI:1083796916
Name:LEGERSKI, DANIEL L (PSY D LP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:LEGERSKI
Suffix:
Gender:M
Credentials:PSY D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WILLSON RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1343
Mailing Address - Country:US
Mailing Address - Phone:952-200-9804
Mailing Address - Fax:952-920-2461
Practice Address - Street 1:5200 WILLSON RD
Practice Address - Street 2:SUITE 205
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1343
Practice Address - Country:US
Practice Address - Phone:952-200-9804
Practice Address - Fax:952-920-2461
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN156798500Medicaid
MN680002678Medicare UPIN