Provider Demographics
NPI:1841780335
Name:PSYCHOLOGY SERVICES OF MINNESOTA, PLLC
Entity Type:Organization
Organization Name:PSYCHOLOGY SERVICES OF MINNESOTA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:218-330-7867
Mailing Address - Street 1:15748 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6176
Mailing Address - Country:US
Mailing Address - Phone:218-330-7867
Mailing Address - Fax:
Practice Address - Street 1:804 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4441
Practice Address - Country:US
Practice Address - Phone:218-829-1407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3464103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty