Provider Demographics
NPI:1598704082
Name:DECKER, DAVID JUDSON (MA, LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JUDSON
Last Name:DECKER
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 DAYTON AVE
Mailing Address - Street 2:SUITE 321
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6206
Mailing Address - Country:US
Mailing Address - Phone:651-646-4325
Mailing Address - Fax:651-646-4325
Practice Address - Street 1:1619 DAYTON AVE
Practice Address - Street 2:SUITE 321
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6206
Practice Address - Country:US
Practice Address - Phone:651-646-4325
Practice Address - Fax:651-646-4325
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 0342103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical