Provider Demographics
NPI:1114028586
Name:MCALLISTER, ROBERT W JR (MA LP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MCALLISTER
Suffix:JR
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S 13TH ST
Mailing Address - Street 2:RANGE MENTAL HEALTH CENTER INC
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-749-2881
Mailing Address - Fax:218-749-3806
Practice Address - Street 1:624 S 13TH ST
Practice Address - Street 2:RANGE MENTAL HEALTH CENTER INC
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-749-2881
Practice Address - Fax:218-749-3806
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2242103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN406348100Medicaid