Provider Demographics
NPI:1942850003
Name:SIMONSON, GREGORY R (PHD, LP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:SIMONSON
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 1:2400 W 64TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 AMERICAN BLVD E STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1230
Practice Address - Country:US
Practice Address - Phone:952-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6448103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical