Provider Demographics
NPI:1205868635
Name:CHAZDON, ELLEN (PSY D LP)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:CHAZDON
Suffix:
Gender:F
Credentials:PSY D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 EDEN AVE
Mailing Address - Street 2:SUITE 117
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2337
Mailing Address - Country:US
Mailing Address - Phone:952-920-9304
Mailing Address - Fax:952-920-9304
Practice Address - Street 1:5100 EDEN AVE
Practice Address - Street 2:SUITE 117
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2337
Practice Address - Country:US
Practice Address - Phone:952-920-9304
Practice Address - Fax:952-920-9304
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3170103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN76D36BROtherBCBS
MN24725OtherDEFINITY
6178275OtherUBH
MN7954181OtherAETNA
MN108515OtherUCARE