Provider Demographics
NPI:1679633093
Name:MINNESOTA CLINICAL & NEUROPSYCHOLOGICAL ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:MINNESOTA CLINICAL & NEUROPSYCHOLOGICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MISUKANIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-876-0727
Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1514
Mailing Address - Country:US
Mailing Address - Phone:952-876-0727
Mailing Address - Fax:952-851-9618
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1514
Practice Address - Country:US
Practice Address - Phone:952-876-0727
Practice Address - Fax:952-851-9618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460980800Medicaid
MN460980800Medicaid