Provider Demographics
NPI:1295167880
Name:DICKSON PSYCHIATRIC SERVICES, PLC
Entity type:Organization
Organization Name:DICKSON PSYCHIATRIC SERVICES, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, PMHNP
Authorized Official - Phone:218-256-7570
Mailing Address - Street 1:6357 MERRIMAC LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3835
Mailing Address - Country:US
Mailing Address - Phone:218-256-7570
Mailing Address - Fax:877-514-9201
Practice Address - Street 1:4300 BAKER RD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-8688
Practice Address - Country:US
Practice Address - Phone:763-200-6161
Practice Address - Fax:877-514-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP-1591363LP0808X
MNR1232699363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty