Provider Demographics
NPI:1659446276
Name:MELLBERG, DAVID BURDETTE (PHD, LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BURDETTE
Last Name:MELLBERG
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12805 HIGHWAY 55
Mailing Address - Street 2:SUITE 211
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3859
Mailing Address - Country:US
Mailing Address - Phone:763-550-9005
Mailing Address - Fax:763-559-2118
Practice Address - Street 1:12805 HIGHWAY 55
Practice Address - Street 2:SUITE 211
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3859
Practice Address - Country:US
Practice Address - Phone:763-550-9005
Practice Address - Fax:763-559-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1979103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical