Provider Demographics
NPI:1912041492
Name:ALTER, DAVID S (PHD LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:ALTER
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 1:10501 WAYZATA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5508
Mailing Address - Country:US
Mailing Address - Phone:763-546-5797
Mailing Address - Fax:763-546-5754
Practice Address - Street 1:10505 WAYZATA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1506
Practice Address - Country:US
Practice Address - Phone:763-546-5797
Practice Address - Fax:763-546-5754
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1585103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680001035Medicare ID - Type UnspecifiedMEDICARE ID