Provider Demographics
NPI:1346661063
Name:CLINICAL AND DEVELOPMENTAL SERVICES LLC
Entity Type:Organization
Organization Name:CLINICAL AND DEVELOPMENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:EGLI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-923-8001
Mailing Address - Street 1:9384 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-9422
Mailing Address - Country:US
Mailing Address - Phone:952-923-8001
Mailing Address - Fax:952-955-6213
Practice Address - Street 1:9384 OAK AVE
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-9422
Practice Address - Country:US
Practice Address - Phone:952-923-8001
Practice Address - Fax:952-955-6213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty