Provider Demographics
NPI:1598900136
Name:FENDT, MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FENDT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-0003
Mailing Address - Country:US
Mailing Address - Phone:651-705-2423
Mailing Address - Fax:
Practice Address - Street 1:360 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2564
Practice Address - Country:US
Practice Address - Phone:651-724-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical