Provider Demographics
NPI:1457748477
Name:DR. ELLEN CHAZDON, PSY.D., L.P., LLC
Entity Type:Organization
Organization Name:DR. ELLEN CHAZDON, PSY.D., L.P., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAZDON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-310-3318
Mailing Address - Street 1:5200 WILLSON RD STE 490
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1398
Mailing Address - Country:US
Mailing Address - Phone:952-920-9304
Mailing Address - Fax:
Practice Address - Street 1:5200 WILLSON RD STE 490
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1398
Practice Address - Country:US
Practice Address - Phone:952-920-9304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3170103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN720817100Medicaid
MN720817100Medicaid