Provider Demographics
NPI:1265462212
Name:NORTH PSYCHOLOGY CLINIC PA
Entity Type:Organization
Organization Name:NORTH PSYCHOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:K
Authorized Official - Last Name:FELTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LP
Authorized Official - Phone:763-531-0566
Mailing Address - Street 1:6120 EARLE BROWN DRIVE STE. 520
Mailing Address - Street 2:NORTH PSYCHOLOGY CLINIC PA
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DRIVE STE. 520
Practice Address - Street 2:NORTH PSYCHOLOGY CLINIC P.A.
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MN261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN30786NOOtherBLUE CROSS BLUE SHIEL
MN973518600Medicaid
MN30787NOOtherBLUE CROSS BLUE SHIELD
MN30786NOOtherBLUE CROSS BLUE SHIEL
MN973518600Medicaid