Provider Demographics
NPI:1356412498
Name:EDELSON, DOROTHY SUE (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:SUE
Last Name:EDELSON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:DR
Other - First Name:DOROTHY
Other - Middle Name:E
Other - Last Name:JAPUNTICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:6120 EARLE BROWN DR
Mailing Address - Street 2:STE. 520
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2123
Mailing Address - Country:US
Mailing Address - Phone:763-531-0566
Mailing Address - Fax:763-531-0602
Practice Address - Street 1:6120 EARLE BROWN DR
Practice Address - Street 2:STE. 520
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2123
Practice Address - Country:US
Practice Address - Phone:763-531-0566
Practice Address - Fax:763-531-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3108101YM0800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN385823500Medicaid
MN66B68EDOtherBLUECROSSBLUESHIELD
MN61-40441OtherMEDICA
MN97351777Medicaid
MN385823500Medicaid
MN61-40441OtherMEDICA