Provider Demographics
NPI:1164559241
Name:IMP, JOHN MICHAEL (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:IMP
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 1:1357 WINDBREAK CT NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-8587
Mailing Address - Country:US
Mailing Address - Phone:507-289-5409
Mailing Address - Fax:
Practice Address - Street 1:300 3RD AVE SE
Practice Address - Street 2:SUITE 405
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-4619
Practice Address - Country:US
Practice Address - Phone:507-288-8544
Practice Address - Fax:507-288-8545
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP38677OtherHEALTHPARTNERS
MN921001033636OtherPREFERRED ONE
MN143305OtherUCARE
MN362J3IMOtherBCBS OF MN