Provider Demographics
NPI:1972682847
Name:BOSCARDIN, JAMES EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:BOSCARDIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 LAWNVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8408
Mailing Address - Country:US
Mailing Address - Phone:612-719-0856
Mailing Address - Fax:651-484-8551
Practice Address - Street 1:8085 WAYZATA BLVD
Practice Address - Street 2:SUITE 100B
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1453
Practice Address - Country:US
Practice Address - Phone:612-719-0856
Practice Address - Fax:651-484-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0709103TA0700X, 103TC0700X, 103TC2200X, 103TF0200X, 103T00000X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710552500Medicaid
MN680000799Medicare ID - Type Unspecified