Provider Demographics
NPI:1457443582
Name:DEVINE, VERNON T (PHD)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:T
Last Name:DEVINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4500 PARK GLEN RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4871
Mailing Address - Country:US
Mailing Address - Phone:952-929-9478
Mailing Address - Fax:952-929-9548
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:SUITE 360
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:952-929-9478
Practice Address - Fax:952-929-9548
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP0131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61-20116OtherUBH
MN1F223DEOtherBCBSMN
MN181547400Medicaid
MN61-20116OtherUBH