Provider Demographics
NPI:1093724049
Name:PACE, WILLIAM WILLARD (PHD, LP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WILLARD
Last Name:PACE
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 DULUTH ST
Mailing Address - Street 2:SUITE 113
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3946
Mailing Address - Country:US
Mailing Address - Phone:651-645-3115
Mailing Address - Fax:651-645-2752
Practice Address - Street 1:5851 DULUTH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3946
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2543103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6800001290Medicare ID - Type Unspecified