Provider Demographics
NPI:1720635519
Name:SOUTHERN MINNESOTA PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTHERN MINNESOTA PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-434-1092
Mailing Address - Street 1:2701 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-5406
Mailing Address - Country:US
Mailing Address - Phone:507-438-3062
Mailing Address - Fax:
Practice Address - Street 1:329 N MAIN ST STE 104L
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3478
Practice Address - Country:US
Practice Address - Phone:507-434-1092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty