Provider Demographics
NPI:1689668931
Name:SCANLON, RICHARD JOHN JR (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:SCANLON
Suffix:JR
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 1:8120 165TH ST E
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-4100
Mailing Address - Country:US
Mailing Address - Phone:612-669-3759
Mailing Address - Fax:
Practice Address - Street 1:6542 REGENCY LN
Practice Address - Street 2:#212
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7847
Practice Address - Country:US
Practice Address - Phone:612-669-3759
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2556103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist