Provider Demographics
NPI:1700852266
Name:LESAR, DAVID J (EDD LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:LESAR
Suffix:
Gender:M
Credentials:EDD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7172
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:1245 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1802
Practice Address - Country:US
Practice Address - Phone:320-253-5200
Practice Address - Fax:320-203-2113
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical