Provider Demographics
NPI:1689648784
Name:KERN, TOM (PHD, LP)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:KERN
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 1:9637 ANDERSON LAKES PKWY
Mailing Address - Street 2:STE. #162
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-4155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11800 SINGLETREE LN
Practice Address - Street 2:#203
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5328
Practice Address - Country:US
Practice Address - Phone:952-944-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0289103G00000X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61-70220OtherMEDICA AND UBH
MN123553OtherUCARE
MN279S6KEOtherBLUE CROSS BLUE SHIELD MN
MNHP30512OtherHEALTHPARTNERS