Provider Demographics
NPI:1710354345
Name:NATHAN, DAVID (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:NATHAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 165TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5729
Mailing Address - Country:US
Mailing Address - Phone:952-435-0022
Mailing Address - Fax:952-435-0095
Practice Address - Street 1:10535 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5729
Practice Address - Country:US
Practice Address - Phone:952-435-0022
Practice Address - Fax:952-435-0095
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6068103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN724402400Medicare Oscar/Certification