Provider Demographics
NPI:1326242702
Name:CENTER FOR PSYCHOLOGICAL AND EDUCATIONAL ASSESSMENT
Entity Type:Organization
Organization Name:CENTER FOR PSYCHOLOGICAL AND EDUCATIONAL ASSESSMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR OF PSYCHOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:PETROS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:701-777-3260
Mailing Address - Street 1:290 CENTENNIAL DR STOP 7108
Mailing Address - Street 2:210 MONTGOMERY HALL
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-6063
Mailing Address - Country:US
Mailing Address - Phone:701-777-3260
Mailing Address - Fax:701-777-3454
Practice Address - Street 1:290 CENTENNIAL DR STOP 7108
Practice Address - Street 2:210 MONTGOMERY HALL
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-6063
Practice Address - Country:US
Practice Address - Phone:701-777-3260
Practice Address - Fax:701-777-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND231103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14870OtherBC BS OF ND
ND10236Medicare ID - Type UnspecifiedNORTH DAKOTA