Provider Demographics
NPI:1518488311
Name:ROSCOE, BRIAN HOWARD (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HOWARD
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:17489 DODD BLVD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6506
Practice Address - Country:US
Practice Address - Phone:952-428-1020
Practice Address - Fax:952-428-1025
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6431103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist